Information Collection

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

IC 213566 under ICR 202101-0938-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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 21 Summary and 21 O MEQC.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form and Instruction
CMS-21 Quarterly Children’s Health Insurance Program Statement 21 Summary and 21 O MEQC.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form and Instruction
CMS-21B Children's Health Insurance Program Budget Report for th 21B Blank Form.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form and Instruction
CMS-21B Children's Health Insurance Program Budget Report for th 21B Blank Form.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form and Instruction

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: Modified

Obligation to Respond: Mandatory

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 and Instruction	CMS-21	Quarterly Childrenâs Health Insurance Program Statement of Expenditures for Title XXI	21 Summary and 21 O MEQC.pdf	https://mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-21B	Children's Health Insurance Program Budget Report for the Title XXI	21B Blank Form.pdf	https://mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Yes	Yes	Fillable Fileable

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
No associated records found

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