Information Collection

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

IC 8399 under ICR 201404-0938-009 · OMB 0938-0731.

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
CMS-21 Quarterly CHIP Statement of Expenditures for Title XXI S CMS 21 Summary.pdf	Form
CHIP Budget Report CMS-12B 21B Summary form.pdf	Form

IC Title:

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	CMS-21	Quarterly CHIP Statement of Expenditures for Title XXI Summary Sheet	CMS 21 Summary.pdf		Yes	Yes	Fillable Printable
Form	CHIP Budget Report For the Title XXI Program State	CMS-12B	21B Summary form.pdf		Yes	Yes	Fillable Printable

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.