View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0270	ICR Reference No: 202408-0938-035
Status: Active	Previous ICR Reference No: 202003-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: The Financial Statement of Debtor and Supporting Regulations in 42 CFR, Section 405.376 (CMS-379 )
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/30/2024
	Date Received in OIRA: 11/05/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2027	36 Months From Approved
Responses	500	0	0
Time Burden (Hours)	1,000	0	0
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $26,410

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Malcolm Wilson 667 414-0087 malcolm.wilson@cms.hhs.gov

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