Information Collection

(149.40) - Updating Data in the Application

IC 201223 under ICR 201202-0938-004 · OMB 0938-1087.

Documents and Forms

Document Name Document Type
CMS-10321.ERRP Application Instructions (508).pdf Instruction
CMS-10321 ERRP Application CMS-10321.ERRP Application (508).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	(149.40) - Updating Data in the Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 149.40

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10321.ERRP Application Instructions (508).pdf		Yes	No	Printable Only
Form	CMS-10321	ERRP Application	CMS-10321.ERRP Application (508).pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Early Retiree Reinsurance Program	FR Citation: 75 FR 31440

Number of Respondents: 916	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	916	916
Annual IC Time Burden (Hours)	916	916
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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