Form CMS-37 State Estimate of Quarterly Grant Awards (In Thousands)

Department of Health and Human Services

OMB No.

0938-0101

Centers for Medicare & Medicaid Services

Medicaid Program Budget Report

State Estimate of Quarterly Grant Awards (In Thousands)

State:

Submission Date:

Contact Name for Information:

Certification Qtr.:

Fiscal Year: (1)

Medical Assistance Payments

State and Local Administration

Federal Share

Total Comp.

Federal Share

State Share

Total Comp.

Federal Share

State Share

M-SCHIP

Fiscal Quarter

A

B

C

D

E

F

G

1.

1st Quarter

2.

2nd Quarter

3.

3rd Quarter

4.

4th Quarter

5.

Total

Fiscal Year: (2)

Medical Assistance Payments

State and Local Administration

Federal Share

Total Comp.

Federal Share

State Share

Total Comp.

Federal Share

State Share

M-SCHIP

Fiscal Quarter

A

B

C

D

E

F

G

6.

1st Quarter

7.

2nd Quarter

8.

3rd Quarter

9.

4th Quarter

10.

Total

I certify that:

1. I am the executive officer of the state agency or his/her designate authorized by the state to submit this form.

2. The fiscal year budget estimates only include expenditures under the Medicaid program under title XIX of the Social Security Act (the Act), and as applicable, under the State

Children's Health Insurance Program (SCHIP) under title XXI of the Act, that are allowable in accordance with applicable implementing Federal, state, and local statutes, regulations,

policies, and the state plan approved by the Secretary and in effect during the fiscal year under title XIX of the Act for the Medicaid program, and as applicable, under title XXI of the Act for the SCHIP.

3. The budget estimates are based upon the most reliable information available to the state.

4. The state and or local funds required to match the state's allowable expenditures during the certification quarter will be available, and such state and/or local funds are in

accordance with all applicable Federal requirements for the non-federal share match of expenditures.

5. The amount of state and local funds available for quarter

for the Medicaid program is

$

.

6. Federal matching funds are not being requested for the certification quarter to match expenditures under any Medicaid state plan amendment under title XIX of the Act and/or

state Child Health Plan amendment under title XXI of the Act that was submitted after January 2, 2001, and that has not been approved by the Secretary effective for the certification

quarter.

7. The information shown above and on the Form CMS-37 summary sheet and the supporting schedules is correct to the best of my knowledge and belief.

Date:

Signature:

Title:

Footnotes:

The completed Budget, Expenditure and supporting forms are to be submitted via the on-line MBES/CBES system to the Centers for Medicare & Medicaid Services, Center for Medicaid and State

Operations, Finance, Systems and Budget Group, Division of Financial Management, located at Mail stop S3-13-15, 7500 Security Blvd., Baltimore, Maryland 21244-1850.

Form CMS-37.1

Report Date: