Information Collection

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

IC 8399 under ICR 201103-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CHIP Statement of Expenditures for the Title X CMS21Forms.pdf	Form and Instruction
CMS-21B State CHIP Budget Report for the Title XXI Program CMS21B.pdf	Form and Instruction
CMS-21and21B - Crosswalk.xlsx CMS-21 & -21B Crosswalk	IC Document

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 CHIP Statement of Expenditures for the Title XXI Program	CMS21Forms.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-21B	State CHIP Budget Report for the Title XXI Program	CMS21B.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
CMS-21 & -21B Crosswalk	CMS-21and21B - Crosswalk.xlsx	03/01/2011

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