Information Collection

Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI

IC 8399 under ICR 200806-0938-003 · OMB 0938-0731.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0731 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-21 Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI	Form and Instruction
CMS-21 Quarterly State Children's Health Insurance Program Stat CMS-21 forms.pdf	Form and Instruction
CMS-21B State Children's Health Insurance Program Budget Report CMS-21b forms.pdf	Form and Instruction

IC Title:

Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-21	Quarterly State Children's Health Insurance Program Statement of Expenditures for Title XXI Summary Sheet	CMS-21 forms.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-21B	State Children's Health Insurance Program Budget Report for Title XXI Program State Expenditure Plan	CMS-21b forms.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	448	448
Annual IC Time Burden (Hours)	7,840	7,840
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.