Information Collection

Income and Eligibility Verification System Reporting and Supporting Regs.

IC 8090 under ICR 202511-0938-019 · OMB 0938-0467.

Documents and Forms

Document Name Document Type
Form CMS-R-74 Income and Eligibility Verification System Reporting and Supporting Regs. Form
Form CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification System (IEVS) - PARIS SPA Template Income and Eligibility Verification System Reporting and Supporting Regs. Form
CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification S IncomeEligibilitySPAPreprintclm508.pdf Form
CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification S IncomeEligibilitySPAPreprintclm508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Income and Eligibility Verification System Reporting and Supporting Regs.	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 435.940-435.960 42 CFR 435.920 42 CFR 431.17 42 CFR 431.306 42 CFR 435.910

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-74	Attachment 4.32-A: Income and Eligibility Verification System (IEVS) - PARIS SPA Template	IncomeEligibilitySPAPreprintclm508.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,241	3,241
Annual IC Time Burden (Hours)	1,082	1,082
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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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