Information Collection

Beneficiaries

IC 257780 under ICR 202504-0938-005 · OMB 0938-1441.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10831 Beneficiaries	Form and Instruction
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (English) Beneficiaries	Form and Instruction
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (English)) Beneficiaries	Form and Instruction
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Chinese)) Beneficiaries	Form and Instruction
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Chinese) Beneficiaries	Form and Instruction
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Korean)) Beneficiaries	Form and Instruction
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Korean)) Beneficiaries	Form and Instruction
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Spanish) Beneficiaries	Form and Instruction
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Spanish) Beneficiaries	Form and Instruction
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Vietnamese) Beneficiaries	Form and Instruction
Form CMS-10831 Direct Reimbursement Request for the Limited Inon (LI NET) Program ()come Newly Eligible Transition(Vietnamese) Beneficiaries	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib Application to Enroll in the LI NET Program-2025revised (clean).docx	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib Application to Enroll in the LI NET Program-2025revised (clean).docx	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program-2025revised (clean).docx	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program-2025revised (clean).docx	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib C Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib C Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl C Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl C Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib K Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib K Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl K Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl K Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib SPA Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib SPA Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl SPA Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl SPA Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib VI Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib VI Application to Enroll in the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Inon (LI NE VI Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Inon (LI NE VI Direct Reimbursement Request for the LI NET Program-2025v3_508.pdf	Form and Instruction
Application to Enroll in the LI NET Program-2025revised.pdf Track Change: Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program	IC Document
Application to Enroll in the LI NET Program-2025revised.pdf Track Change: Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program	IC Document
Direct Reimbursement Request for the LI NET Program-2025revised.pdf Track Change: Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program	IC Document
Direct Reimbursement Request for the LI NET Program-2025revised.pdf Track Change: Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Beneficiaries

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10831	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36,982

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	36,982	36,982
Annual IC Time Burden (Hours)	9,246	9,246
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change: Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program		04/04/2025
Track Change: Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program		04/04/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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