View Information Collection (IC)

IC Title:	Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 430.10 42 CFR 430.20 42 CFR 440.167

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-179				Yes	No	Fillable Printable

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,681	4,625	56
Annual IC Time Burden (Hours)	9,271	8,711	560
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
DCIS att 4 39A		01/09/2009
DCIS att 4 39B		01/09/2009
DCIS sec 4 39 PASRR		01/09/2009
DEH rev4 17 Liens Adj Rec p53 No Att		01/09/2009
DEH rev4 22 Base Plan TPL p69,69a,70		01/09/2009
DEH rev 2 PRA Base Plan Territory-Section2		01/09/2009
DEH rev PRA Base Plan PRA State-Section2		01/09/2009
DEH Section 3 pages PRA version 7 10 08		01/09/2009
DEH_State 2 6-A PRA (2)		01/09/2009
DEH_State 2		01/09/2009
DEH_State-Section2 Base		01/09/2009
DEH_Territory-2 2-A PRA508		01/09/2009
DEH_Territory-2 6-A PRA (2)		01/09/2009
DEH_Territory-Section2 Base		01/09/2009
Exhibits for Base Plan PRA Pages		01/09/2009
FCH rev 431_434		01/09/2009
FMG rev4 19 b - DP Revision 07-17-08		01/09/2009
FMG4 19b preprint 7-29-08		01/09/2009
FMG rev4 19 (k) page 66a		01/09/2009
FMG rev4 19 Att 4 19-B sec 24p1a		01/09/2009
FMG rev4 19 B supp1 preprint		01/09/2009