View Information Collection (IC)

View Information Collection (IC)

IC Title:	GenIC #63 (Transfer) - 1932(a) State Plan Amendment Template	Agency IC Tracking Number:	CMCS

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10120	1932(a) State Plan Amendment Template	1932a State Plan Preprint- 508 approved 2020 version 2.pdf		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: 56	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	12	0	12	0	0	0
Annual IC Time Burden (Hours)	70	0	70	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Supporting Statement	63 - Generic Supporting Statement (2020 version 3).docx	05/26/2020

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