Information Collection

Individual Application

IC 205692 under ICR 202506-0938-003 · OMB 0938-1191.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1191 can be found here:

2025-07-09 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10440 Individual Application	Form and Instruction
Form CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) Individual Application	Form and Instruction
Form CMS-10440 Application for Health Coverage & Help Paying Costs Individual Application	Form and Instruction
Form CMS-10440 Application for Health Coverage (no cost help) Individual Application	Form and Instruction
Form CMS-10440 Electronic application. Individual Application	Form
Form CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) - Spanish Individual Application	Form and Instruction
Form CMS-10440 Application for Health Coverage & Help Paying Costs - Spanish Individual Application	Form and Instruction
Form CMS-10440 Application for Health Coverage (no cost help) - Spanish Individual Application	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att-B individual-short-form-clean-508-2 2025.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att-B individual-short-form-clean-508-2 2025.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att-C marketplace-consumer-application-family-clean-508-2 2025.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att-C marketplace-consumer-application-family-clean-508-2 2025.pdf	Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att-D marketplace-application-without-financial-assistance-clean-508.pdf	Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att-D marketplace-application-without-financial-assistance-clean-508.pdf	Form and Instruction
CMS-10440 Electronic application. Att A.-Application PRA Electronic Application 022825 Clean.xlsx	Form
CMS-10440 Electronic application. Att A.-Application PRA Electronic Application 022825 Clean.xlsx	Form
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att-B individual-short-form-spanish-clean-2 2025.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att-B individual-short-form-spanish-clean-2 2025.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs - Sp Att-C marketplace-consumer-application-family-spanish-clean-2 2025.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs - Sp Att-C marketplace-consumer-application-family-spanish-clean-2 2025.pdf	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	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	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Individual Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 26 CFR 1 and 602 42 CFR Parts 431, 435, 457 45 CFR Parts 155, 156, 157 (To search for a specific CFR, visit the Code of Federal Regulations.)

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-10440	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Yes	Yes	Fillable Fileable
Form	CMS-10440	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	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: 800,467

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	800,467	-10,526,573	11,327,040
Annual IC Time Burden (Hours)	7,019,109	-86,343	7,105,452
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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