Information Collection

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

IC 213566 under ICR 202611-0938-007 · OMB 0938-1265.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-21 (Series) 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 CMS-21B)	Form
CMS-21 (Series) Quarterly Children’s Health Insurance Program Statement Expenditure_21_Q1_2027_Report.xlsx	Form
CMS-21.O.pdf CMS-21.O	IC Document

IC Title:

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	CMS-21 (Series)				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
	Requested	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
CMS-21.O		11/06/2026

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

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