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

Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and 21B)

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.