Information Collection

Model Application Template for State Child Health Insurance Plan under Title XXI of the Social Security Act, State Children's Health Insurance Program and Supporting Statute Title XXI of the

IC 8343 under ICR 199709-0938-005 · OMB 0938-0707.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0707 can be found here:

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Information Collection (IC) Details

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IC Title:	Model Application Template for State Child Health Insurance Plan under Title XXI of the Social Security Act, State Children's Health Insurance Program and Supporting Statute Title XXI of the	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-211				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	8,980	8,980
Annual IC Cost Burden (Dollars)	0	0

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