Information Collection

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

IC 213566 under ICR 201609-0938-003 · OMB 0938-1265.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1265 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 (CMS-21 and CMS-21B)	Form and Instruction
CMS-21 Quarterly Children’s Health Insurance Program Statement CMS 21 Base.docx	Form and Instruction
CMS-21B Quarterly Children’s Health Insurance Program Statement CMS 21B.docx	Form and Instruction
CMS-21 Nonsubstantive Change to CMS-21 Summary CMS 21 Summary.pdf	Form
Form Descriptions.docx Form Descriptions	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-21	Quarterly Childrenâs Health Insurance Program Statement of Expenditures for Title XXI	CMS 21 Base.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-21B	Quarterly Childrenâs Health Insurance Program Statement of Expenditures for Title XXI	CMS 21B.docx	Yes	Yes	Fillable Printable
Form	CMS-21	Nonsubstantive Change to CMS-21 Summary	CMS 21 Summary.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	224	224
Annual IC Time Burden (Hours)	4,480	4,480
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Form Descriptions	Form Descriptions.docx	10/22/2014

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