Form ORR-1 Cash and Medical Assistance Estimates

Refugee Resettlement Program Estimates: CMA

ORR-1.xlsx

Refugee Resettlement Program Estimates: CMA

OMB: 0970-0030

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Department of Health and Human Services


OMB N0. XXXX-XXXX
Administration for Children and Families


Approval Expires X/X/XX
OFFICE OF REFUGEE RESETTLEMENT
ORR-1 CASH AND MEDICAL ASSISTANCE PROGRAM ESTIMATES
Grantee: ________________ ___________________________________________________________ Federal Fiscal Year: ______________________





Cash and Medical Assistance Estimated Average Estimated Average Estimated Total Fiscal
Program Components Monthly Unit Cost Monthly Recipients/Users Year Expenditures/1
(Column A) (Column B) (Column C) (Column D)
1. Refugee Cash Assistance (RCA) (a) RCA Recipient Costs


(b) RCA Administration


(c) Subtotal


2. Refugee Medical Assistance (RMA) (a) RMA Recipient Costs


(b) RMA Administration


(c) Medical Screening/2


(d) Medical Screening Administration/2


(e) Subtotal


3. Unaccompanied Refugee Minors (URM) (a) Services for URMs


(b) URM Program Administration


(c) Subtotal


4. Administration - Program Coordination and Planning/3


5. Total Administration/4


6. Total Estimate/5


Signature of Approving Official Name and Title of Approving Official Date Report Submitted:



Telephone Number:
E-mail Address:
1/ To annualize monthly costs for rows 1(a), 2(a), 2(c), and 3(a), multiply the figure in column B by the figure in column C and then multiply by 12.



2/ Include only medical screening and medical screening administration costs paid through RMA.



3/ In accordance with 45 CFR 400.13c.



4/ Total Administration equals sum of lines 1(b), 2(b), 2(d), 3(b), and 4 of column D.



5/ Total Estimate equals sum of lines 1(c), 2(e), 3(c), and 5 of column D.



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