Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1073 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10295 Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295) Form and Instruction
CMS-10295 State Report on the Use of Increase FMAP Section 5001 of 08-20-09 ARRA-Sec-5001-State-Report-3.pdf Form and Instruction
CMS-10295 State Report on the Transitional Medical Assistance Sect 08-20-09 ARRA-Sec-5004-State-Report-3.pdf Form and Instruction
Disclosure Statement for Section 5001.DOC Disclosure Statement for Section 5001 IC Document
Disclosure Statement for Section 5004.DOC Disclosure Statement for Section 5004 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Recovery Act - Reporting Requirements for States Under FMAP Increase and TMA Provisions (CMS-10295)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10295	State Report on the Use of Increase FMAP Section 5001 of ARRA	08-20-09 ARRA-Sec-5001-State-Report-3.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10295	State Report on the Transitional Medical Assistance Section 5004 of ARRA	08-20-09 ARRA-Sec-5004-State-Report-3.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Disclosure Statement for Section 5001	Disclosure Statement for Section 5001.DOC	09/16/2009
Disclosure Statement for Section 5004	Disclosure Statement for Section 5004.DOC	09/16/2009

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