CMS-10549.GenIC#3 - Att. G Participant Fee Receipt

NORC at the University of Chicago

Participant Fee Receipt Form

Instructions: Please sign your name below to indicate that you have read this Fee Receipt and have received the payment.

I have received $40.00 (cash) from an NORC staff member for participating in this interview.

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Participant Signature

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Month Day Year

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1275 (expires 05/31/2021). The time required to complete this information collection is estimated to average 70 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact MCBS@cms.hhs.gov.

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