CMS-21B State CHIP Budget Report for the Title XXI Program

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 8/31/2011
Quarterly Children's Health Insurance Program Budget Report
For the Title XXI Program State
Expenditure Plan (In Thousands)

State:
Submission Date: 11/15/2010
Certification Qtr:
Program:
Fiscal Year and Quarter
1 2011
2 2011
3 2011
4 2011
5 2011
6 2012
7 2012
8 2012
9 2012
10 2012

Total Computable
(A)

Federal Share
(B)

State Share
(C )

Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total
Quarter 1
Quarter 2
Quarter 3
Quarter 4
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 Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act (the Act) that are
allowable in accordance with applicable implementing federal, state and local statutes, regulations, policies, and the Children Health Plan approved by the Secretary and in
effect during the fiscal year under Title XXI of the Act.
3. The budet 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 expeditures 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. Federal matching funds are not being requested for the certification quarter to match expenditures under a Children Health Plan amendment under Title XXI of the Act that
was submitted after January 2, 2001, and has not been approved by the Secretary effective for the certification quarter.
6. The information shown on the Form CMS-21B is correct to my knowledge and belief.
Date:

Signature:

Title:

User Performing Certification:

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 Quality Group, Division of Financial Management, located at Mailstop S3-13-15, 7500 Security Blvd., Baltimore, Maryland 21244-1850.

Form CMS 21.B Summary

Report Date: Monday, November 15, 2010 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 8/31/2011

Quarterly Children's Health Insurance Program Budget Report
For the Title XXI Program State
Expenditure Plan (In Thousands)
State:
Submission Date: 11/15/2010
Certification Qtr:
Program:
Fiscal Year and Quarter
1 2011
2 2011
3 2011
4 2011
5 2011
6 2012
7 2012
8 2012
9 2012
10 2012

Total Computable
(A)

Federal Share
(B)

State Share
(C )

Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total

Date:

Signature:

Title:

User Performing Certification:

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 Quality Group, Division of Financial Management, located at Mailstop S3-13-15, 7500 Security Blvd., Baltimore, Maryland 21244-1850.

Form CMS 21.B

Report Date: Monday, November 15, 2010 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-0731
Expires 8/31/2011

Quarterly Children's Health Insurance Program Budget Report
21B Narratives
State:
Submission Date: 11/15/2010
Certification Qtr:
Other Narrative Explanations

Form CMS 21B Narr

Report Date: Monday, November 15, 2010 - 12:00 AM