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Federal forms, ICRs, and supporting documents

Information Collection

Individual Application

IC 205692 under ICR 202504-0938-017 · OMB 0938-1191.

Documents and Forms
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Information Collection (IC) Details

View Information Collection (IC)

Individual Application
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR Parts 155, 156, 157 26 CFR 1 and 602 42 CFR Parts 431, 435, 457  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) Att-B individual-short-form-clean-508-2 2025.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Application for Health Coverage & Help Paying Costs Att-C marketplace-consumer-application-family-clean-508-2 2025.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Application for Health Coverage (no cost help) Att-D marketplace-application-without-financial-assistance-clean-508.pdf Yes Yes Fillable Fileable
Form CMS-10440 Electronic application. Att A.-Application PRA Electronic Application 022825 Clean.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) - Spanish Att-B individual-short-form-spanish-clean-2 2025.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Application for Health Coverage & Help Paying Costs - Spanish Att-C marketplace-consumer-application-family-spanish-clean-2 2025.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Application for Health Coverage (no cost help) - Spanish Att-D marketplace-application-without-financial-assistance-spanish-clean-2 2025.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

11,327,040 0
   
Individuals or Households
 
   90 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11,327,040 0 0 0 0 11,327,040
Annual IC Time Burden (Hours) 7,105,452 0 0 0 0 7,105,452
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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