View Information Collection (IC)

View Information Collection (IC)

IC Title:	Bundle (2 GenICs) - PERM Pilot (#20) and FMAP Claiming (#21)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#20)	PERM Pilot Submission Template	PERM Pilot Proposal Submission State Template.xlsx		Yes	Yes	Fillable Printable
Instruction			FMAP Claiming SPA Instructions.docx		Yes	No	Printable Only
Form	CMS-10398 (#21)	Threshold Methodology for Identification of Applicable FMAP Rates	FMAP Claiming SPA 9-16-13-Attachments.docx		Yes	Yes	Fillable Printable

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: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	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	52	0	0	0	0	0
Annual IC Time Burden (Hours)	2,240	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
PERM - Supporting Statement	PERM Supporting Statement.docx	09/19/2013
FMAP Claiming - Supporting Statement	FMAP Claiming SPA Supporting Statement.docx	09/19/2013

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