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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

40 Approval Date:

Federal Share

$ 25,564,870 $

$ 25,56 State Share

$ 8,331,802 $

$ 8,33 TOTAL COSTS OF APPROVED SCHIP PLAN

$ 33,896,672 $

$ 33,89

Beneficiary cost-sharing payments have been accounted for and Net Benefit costs are net of the cost-shar

The Source of State Share Funds:_ State General Funds_______________________________________