View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0270	ICR Reference No: 201612-0938-002
Status: Historical Active	Previous ICR Reference No: 201309-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-379
Title: The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/13/2017
	Date Received in OIRA: 12/23/2016
Terms of Clearance: The expiration date for the approved form is now March 2020. CMS requested a July 2020 expiration, but that is beyond the time granted by this approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	500	0	500
Time Burden (Hours)	1,000	0	1,000
Cost Burden (Dollars)	0	0	0

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