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ffim" CHIP Eligibility PRA Disclosure Statement Acoording 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. Thevalid OMB control num ber for this inform ation collect¡on is 093 8- I 148. The time required to complete this information colt€ction is est¡mated to average 50 hours per response, includ¡ng the time to review instruct¡ons, search ex¡st¡ng data resources, gather the data needed, and complete and review the information collection. Ifyou have comments çoncerning the accuracy of the time €stimate(s) or suggestions for improving this form, please write to: CMS,7500 Secur¡ty Boulevard, Attn: PRA R€ports Clearance Officer, Mail Stop C4-26-05, Baftimorc, Morylond 21244-1850. , ruror.,r, 201 of 1, 3 sPA# CA-17-0045 Approval DEC 2 7 zglt Effective Date: July Page