Form CMS-10398 (#25) CMS-10398 (#25) Tobacco Cessation Quitline Expenditures – Participation

OMB Control Number 0938-1148

Expiration date: 10/31/2014

Tobacco Cessation Quitline Expenditures – Participation in Medicaid Administration Federal Financial Participation (FFP)

State/Territory:
Submission Date: (MM/DD/YYYY)

State Contact	Name:
	Title:
	Office, Group or Division:
	Telephone:
	Email:

Has your state submitted any claims on the Form CMS-64.10 (State and Local Administration) for expenditures related to tobacco cessation telephone quitline activities during Federal Fiscal Year (FFY) 2012?

Yes

No

As of the federal fiscal quarter ending June 30, 2012, was your state claiming administrative FFP for tobacco cessation quitline expenditures?

Yes

No

What is the total amount (Total Computable) of all claims your state has submitted on the Form CMS-64.10 (State and Local Administration) for tobacco cessation telephone quitline expenditures during FFY 2012?

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