View Information Collection (IC)

View Information Collection (IC)

GenIC #1 (Extension) - Initial Application
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10434 #1 Initial Application Combined #1 Initial Application Combined.pdf Yes Yes Fillable Fileable
Form CMS-10434 #1 Initial Application SPA Admin 1 - Initial Application SPA Admin.pdf Yes Yes Fillable Fileable
Form CMS-10434 #1 Initial Application 1 - Initial Application.pdf Yes Yes Fillable Fileable
Other-PRA Disclosure Statement PRA Disclosure Statement 082919 (rev 08-30-2019).pdf No   Printable Only

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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 56 0 56 0 0 0
Annual IC Time Burden (Hours) 476 0 476 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
GenIC Supporting Statement 1 - Supporting Statement Initial Application Templates 082919.docx 08/30/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.