Form CMS-21 Quarterly CHIP Statement of Expenditures for Title XXI S

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

OMB No. 0938-0731
Expires 04/30/2014

Quarterly Children's Health Insurance Program
Statement of Expenditures for Title XXI
Summary Sheet
State:

Quarter Ended:
Title XXI Expenditures

Expenditures Reported for Period

1

Expenditures In This Quarter (Form CMS 21 Base)

2

Adjustments Increasing Claims For Prior Quarters (Form CMS 21P)

3

Adjustments Decreasing Claims For Prior Quarters (Form CMS 21P)

4

Adjustments/Decreasing Claims - Perm (Form CMS 21Perm)

5

Adjustments - Decreasing Claims - Overpayments

6

Net Expenditures Reported In This Period

Total Computable

Federal Share

(A)

(B)

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. This report only includes expenditures under the Children’s Health Insurance Program (CHIP) under Title XXI of 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 in the Quarter Ended indicated above under Title XXI of the Act.
3. The expenditures included in this report are based on the state's accounting of actual recorded expenditures, and are not
based on estimates.
4. The required amount of state and/or local funds were available and used to match the state’s allowable expenditures
included in this report, and such state and/or local funds were in accordance with all applicable federal requirements for the
non-federal share match of expenditures.
5. Federal matching funds are not being claimed on this report to match any expenditure under any Children Health Plan
amendment that was submitted after January 2, 2001, and that has not been approved by the Secretary effective for the Quarter
Ended indicated above.
6. The information shown above and on the Form CMS-21 Summary Sheet and the Supporting Schedules is correct to the best
of 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 Summary Sheet

Report Date: Tuesday, February 04, 2014 -