Information Collection

Self-Certification & Notice to HHS

IC 228591 under ICR 202602-0938-008 · OMB 0938-1344.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10653 EBSA FORM 700 - Certification Form Self-Certification & Notice to HHS	Form and Instruction
CMS-10653 EBSA FORM 700 - Certification Form CMS-10653 Certification.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.131(c)(3)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10653				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	1	1

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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