Orr-1

Department of Health and Human Services			OMB No. 0970-0030 Approval Expires 02/28/11
Administration for Children and Families
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			$	6
Child welfare services for
unaccompanied minors	$		$	7
(including admininstration)
		Total
		Estimate d/	$	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/ Total equals sum of lines 1, 2, 3, 6, and 7 of column 4.