Individual Application

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)

Documents and Forms

Document Name Document Type
Form CMS-10440 Individual Application Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att-B individual-short-form-clean-508-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att-C marketplace-consumer-application-family-clean-508-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att-D marketplace-application-without-financial-assistance-clean-508.pdf Form and Instruction
CMS-10440 Electronic application. Att A.-Application PRA Electronic Application 022825 Clean.xlsx Form
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att-B individual-short-form-spanish-clean-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs - Sp Att-C marketplace-consumer-application-family-spanish-clean-2 2025.pdf Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) - Spanish Att-D marketplace-application-without-financial-assistance-spanish-clean-2 2025.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Individual Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR Parts 155, 156, 157 26 CFR 1 and 602 42 CFR Parts 431, 435, 457 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs (Short Form)	Att-B individual-short-form-clean-508-2 2025.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs	Att-C marketplace-consumer-application-family-clean-508-2 2025.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage (no cost help)	Att-D marketplace-application-without-financial-assistance-clean-508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10440	Electronic application.	Att A.-Application PRA Electronic Application 022825 Clean.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs (Short Form) - Spanish	Att-B individual-short-form-spanish-clean-2 2025.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs - Spanish	Att-C marketplace-consumer-application-family-spanish-clean-2 2025.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage (no cost help) - Spanish	Att-D marketplace-application-without-financial-assistance-spanish-clean-2 2025.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800,467	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	800,467	-10,526,573	11,327,040
Annual IC Time Burden (Hours)	7,019,109	-86,343	7,105,452
Annual IC Cost Burden (Dollars)	0	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.