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

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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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