Form 1 CMA

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Overview

98-ORR-1
01-ORR-1

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Sheet 1: 98-ORR-1

Department of Health and Human Services OMB No. 0970-0030
Administration for Children and Families Approval Expires 04/30/01			Approval Expires: 02/29/2008
Refugee Resettlement Program Estimates: CMA
(Cash/Medical/Administration/Unaccompanied Minors)
State:____________		Federal Fiscal Year:______Date:__________
Col. 1	Col. 2	Col. 3	Col. 4
	Estimated	Estimated	Estimated
Cash/Medical	Average Monthly	Average Monthly	Fiscal Year
Administration	Unit Cost	Recipients/Users	Expenditures a/
Cash assistance:
RCA recipients	$		$	1
Medical assistance:
Health Screenings b/	$		$	2
RMA recipients	$		$	3
Administration:
Overall management c/			$	4
Provision of RCA/RMA			$	5
Total administration/d			$	6
Child welfare services for
unaccompanied minors	$		$	7
(including admininstration)
		Total
		Estimate e/	$	8
Signature: Approving Official		Typed Name and Title
Date Submitted		Agency Name
a/ To annualize monthly costs, first multiply column 2 by column 3 and then multiply by 12.
b/ Include only health screening costs paid through RMA.
c/ In accordance with 45 CFR 400.13(c).
d/ Line 6 equals sum of lines 4 and 5
e/ Total equals sum of lines 1,2,3,6, and 7 of column 4.
_________________
THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average one hour for reviewing instruction
gathering and maintaining the data needed, and thrity minutes for preparing and completing the form.
An agency may not conduct or sponsor, and a person is not required to redpond to, a collectio of information unless
a currently valid OMB control number.

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Sheet 2: 01-ORR-1

Department of Health and Human Services OMB No. 0970-0030
Administration for Children and Families Approval Expires 04/30/01
Refugee Resettlement Program Estimates: CMA
(Cash/Medical/Administration/Unaccompanied Minors)
State:____________		Federal Fiscal Year:______Date:__________
Col. 1	Col. 2	Col. 3	Col. 4
	Estimated	Estimated	Estimated
Cash/Medical	Average Monthly	Average Monthly	Fiscal Year
Administration	Unit Cost	Recipients/Users	Expenditures a/
Cash assistance:
RCA recipients	$		$	1
Medical assistance:
RMA recipients	$		$	2
Administration:
Overall management b/			$	3
Provision of RCA/RMA			$	4
Total administration			$	5
Child welfare services for
unaccompanied minors	$		$	6
(including admininstration)
		Total
		Estimate c/	$	7
Signature: Approving Official		Typed Name and Title
Date Submitted		Agency Name
a/ To annualize monthly costs, first multiply column 2 by column 3 and then multiply by 12.
b/ In accordance with 45 CFR 400.13(c).
c/ Total equals sum of lines 1, 2, 5, and 6 of column 4.