Form 1 Emergency Repatriation Financial Form

OMB Control No: 0970-0474

Expiration date: 03/31/2019

DEPARTMENT OF HEALTH & HUMAN SERVICES (HHS)

ADMINISTRATION FOR CHILDREN AND FAMILIES (ACF)

330 C Street S.W., Washington D.C. 20201

U.S. REPATRIATION PROGRAM

Emergency and Group Repatriation

Financial Form

(NOTE: Instructions are in the back of this form. Use additional pages where space on this form is insufficient or continue on reverse side)

Name of Agency/Address

Select the one that applies State A uthorized Support Agency

For the Period: MM/DD/YYYY From: _______/_______/________ To: ______/_______/________

Nature of Claim Final Revision

Were services provided at a military base? Yes No

Total # of evacuees serviced

Total # or Emergency Repatriation Centers (ERC)

8. List of ERC managed locations:

9. Expenditures: Insert total actual costs, no estimates. Expenditures included should be on an as-paid basis (e.g. checks issued).

Expenditure	Total		Expenditure		Total
Airport Cost	$		Staff Time		$
Cash	$		Supplies		$
Congregate Feeding	$		Transportation		$
Emergency Repatriation Center (ERC) space	$		Emergency medical services		$
ERC Safety and Security	$		Other Costs (specify)		$
Equipment	$		Other Costs (specify)		$
Escort services	$		Other Costs (specify)		$
Shelter	$		Other Costs (specify)		$
By signing this form the signatory acknowledges that he/she has requisite authority to certify and submit this form. In addition, by signing this form the signatory certifies that the above information is correct to the best of his/her knowledge and that payment for these expenditures has not been received nor previously submitted.
Agency and Address			Telephone/E-mail/Fax
Print Name of Agency Official – Sign Blank space: Use this section for comments or to provide additional information.				Date

Title 18 of the United States Code 1001 states that an individual who “knowingly and wilfully - (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry; shall be fined under this title, imprisoned not more than 5 years…or both”

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 0.30 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

OMB Control No: 0970-0474

Expiration date: 03/31/2019

Administration for Children and Families (ACF)

U.S. Repatriation Program

330 C Street S.W., Washington D.C. 20201

Emergency and Group Repatriation

Financial Form: Expenditure Statement for Reimbursement

General Instructions

General: This form should be completed by the state designated agency and ACF authorized support agency to request reimbursement of reasonable and allowable costs incurred as a result of (1) ACF activation of the State Emergency Repatriation Plan (SERP), or (2) ACF interagency agreement, or similar mechanism, in support of an emergency or group repatriation. By completing this form signatory confirms that identified expenditures have been made in accordance with Public Law 87-64 or Public Law 86-571, and all policies and procedures prescribed for the U.S. Repatriation Program (Program). This form should be used as the cover sheet for financial claims requests. Reimbursement is contingent upon availability of the U.S. Repatriation Program funds.

If any item claimed as expenditure is paid and later canceled, voided, or refunded (e.g. not needed or changed in amount) it should be reported immediately to ACF. The state or support agency should provide a brief explanation of the situation. In addition, the state must issue a check or authorized form of payment to the U.S. Government designated agency.

Fiscal records supporting expenditures, including vendor bills, invoices, vouchers receipts, and cleared checks will be maintained by the state and/or agency and identified for audit purposes.

When to submit a financial claim: Claims are to be submitted within 30-day after the ACF notice to close the Emergency Repatriation Center is received, or upon successful completion of established ACF agreement (e.g. IAA). Signed form with supporting documentation should be sent to the designated ACF staff or ACF designee. If the claim cannot be submitted within the 30-day period, the state or support agency should submit timely notification to ACF in writing providing an explanation and requesting an extension. Requests should be sent to the above address or via e-mail to the designated ACF staff. This prompt notification is critical and necessary in order to ensure that the claim will be considered when received.

When completing this claim, agencies should:

1. Submit a single consolidated claim per state containing all reasonable and allowable expenses incurred by state agencies and/or authorized support agencies. Federal agencies’ costs should not be included with the state claim. The American Red Cross may submit its claim directly to ACF or through the state.

2. Reimbursement is based on supporting documentation and must be able to withstand an audit. Documentation should be provided for both administrative and actual temporary service expenses. See attached supporting documentation instruction sheet for information regarding required documentation. Under special circumstances and for some expenses, written statements may be an acceptable form of supporting documentation.

3. Use this form as a summary sheet for all incurred expenses. Information provided should be actual, no estimates.

4. For information on how to submit this claim electronically, please contact the Program at the above address or telephone number. During an emergency repatriation, contact the U.S. Repatriation Program designated staff.

Instructions for preparing this form: reimbursement is contingent upon proper supporting documentation (e.g. receipts, signed vouches, case management notes, and bills) and available Repatriation Program funds.

1. Item #1: name and address of the agency authorize to submit this claim on behalf of the state.

2. Item #2: check whether this claim is completed on behalf of a state agency or an authorized support agency (e.g. authorized hospital, American Red Cross).

3. Item #3: indicate the calendar period during which the expenditures were incurred and for which reimbursement is claimed.

4. Item #4: check the type of claim submitted

1. Final: to the best of the agency knowledge this is the actual final claim.

2. Revision: if any item is claimed as an expenditure in a previous submission is later cancelled, voided, corrected, or refunded (e.g. not needed or changed in amount), it must be reported and this form should be completed only with the corrections. Provide a brief explanation, including reference to the period indicated on the related claim previously paid. Under certain circumstances, the agency may need to repay or reimburse ACF for the funds previously disbursed, canceled, or refunded. Instructions will be provided by authorized ACF if there is a need to repay or reimburse ACF.

5. Item #5: check yes if the state provided any support and/or services at a military installation and is claiming costs.

6. Item #6: enter the total number of evacuees served by the state, include eligible repatriates and non-eligible repatriates. Add each Emergency Repatriation Center (ERC) total evacuee number, both commercial and military base.

7. Item #7: indicate the number of ERCs managed by the state. For instance two commercial airports and one military base, the total will be 3 ERCs.

8. Item #8: List the name of each ERC location. For instance: (1) Miami International Airport, (2) McGuire Air Force Base.

9. Item #9: Use the below table as a guide to identify the total costs per expenditure. For questions related to this section, please contact ACF.

Expenditure	Description	Forms and/or supporting documentation
Airport CosT	Reasonable expenses associated to the establishment and operations of the ERC at the airport.	Provide an itemized bill. If applicable, provide copies of receipts and other types of supporting documentation.
Cash	Cash will only be provided to eligible individuals. Generally, the state may provide up to $50 dollars per person but no more than $200 per family. This amount may change based on ACF guidance. Cash can be provided using tools such as debit cards.	In order to receive reimbursement for cash assistance provided to eligible repatriates, states must submit with their claims: (1) copy of the repatriate’s approved HHS Emergency and Group Repatriation Assessment Form, (2) HHS Repayment Agreement Form, (3) proof of citizenship (e.g. copy of the passport biographical information or other Federal agency authorized documentation), and (4) proof of cash amount provided to the repatriate (e.g. copy of signed voucher). On the claim, the state is to provide the total number of eligible individuals who received this assistance.
Congregate Feeding	Food will usually be provided to evacuees in conjunction with and following their arrival at the ERC. Consideration must be given to special feeding requirements of many evacuees such as diabetics, infants. Planning should involve consultation with appropriate experts such as clinicians and dieticians/nutritionists.	Provide an itemized bill. If applicable, provide copies of receipts and other types of supporting documentation.
Emergency Repatriation Center (ERC) space	Costs associated with the physical ERC (space lease or contract). Generally, it may include minor modifications for the purpose of making the physical location available to provide services to evacuees. In addition, it may include cleaning and restoration of proven damaged areas.	Provide receipts and/or rental agreement. If claiming restoration of damage areas, the state must include pictures and/or videos of how the area looked immediately before or after ACF activation of the SERP but prior to the first plane arrival with evacuees.
ERC Safety and Security	Reasonable and cost efficient safety and security personnel costs are generally eligible for reimbursement.	When applicable, provide necessary receipts. Look at the staff time section of this document for more information. Standby time is not eligible for reimbursement.
Emergency medical services	Congregate Medical Services: include all expenditures for medical or related services paid to other than hospitals, including physicians, druggists, etc. These services will be provided at the ERC to all arriving and needed evacuees. The purpose will be to provide first aid, screening of evacuees, assessment and treatment of minor illnesses and injuries, and making referrals to 911 or hospitals. The ERC may be staffed with emergency medical technicians, paramedics, nurses, and/or physicians. The number of emergency medical staff will vary according to the number of arriving evacuees and type of evacuation. Pharmaceuticals: This may vary depending on the type of emergency evacuation. ERC will provide emergency aid to the evacuees. Ambulance: transportation to a hospital or other medical facility may be eligible. Use FEMA’s ambulance rates as a guide. Hospitalizations: Only eligible repatriates are generally eligible to receive this type of assistance through the Program. The Repatriation Program is generally the payor of last resort and will not supplement and/or cover for unpaid health coverage or insurance expenses. Reimbursement should first be sought from other potential health insurance or health coverage programs or such as Medicaid, Medicare, and/or other third party provider. Hospital bills may be reimbursed for services provided to eligible repatriates, when no other resources are available. The Program will reimburse reasonable and allowable medical costs using the Medicaid and/or Medicaid rates. Immediately upon arrival to the health institution, the Repatriation Program Temporary Health Service Letter should be provided to the institution. Personnel from the medical institution and/or state are to assist repatriates with timely application of available benefits including health insurance or health coverage programs such as Medicaid, Medicare, etc. Long term treatments are not authorized by the Program. Other costs should be specified. Contact ACF at the above number or during an event, contact the ACF designated staff for clarification and guidance regarding these potential expenses. Some costs may require ACF approval prior to incurring.	Look under the personnel section of this document for more information regarding reimbursement of staff time. Necessary and reasonable emergency medical aid supplies are generally covered. Provide an itemized bill of all incurred costs. Whenever necessary, provide a supporting statement or explanation of cost. Indicate the total number of evacuees provided with this assistance. For unusual expenses, request federal approval, and/or when authorized attach a statement to justify the expenditure. Provide an itemized bill with associated costs. Whenever necessary, provide a supporting statement or explanation of cost. Indicate the total number of evacuees who received some type of pharmaceuticals at the ERC and the type. For instance, 50 received some type of pharmaceuticals. Out of the 50, 30 received insulin, 20 pain killer (include name of pain killer). Use the FEMA current reimbursement rate for ambulance as guidance to calculate cost. http://www.fema.gov/schedule-equipment-rates. Ambulance will only be reimbursed whenever utilized. Standby time may not be eligible for reimbursement. Provide the total number of ambulances utilized during the event, and total number of evacuees who received transportation assistance. If requesting reimbursement, the state and/or medical facility must provide proof that Medicaid, Medicare, and/or other potential health coverage program or plan declined reimbursement of the hospital bill in part or full. A letter from those health companies with explanation for the denial could be utilized as supporting documentation. When requesting reimbursement from the Program, itemized hospital bills should be calculated at a Medicare or Medicare rate. Along with the claim, the state is to provide general biographical information of the eligible repatriate, hospital name and address, and hospital point of contact information. In addition, a copy of the repatriate’s HHS Emergency and Group Assessment Form, and HHS Repayment Agreement Form must accompany the claim. Provide an itemized bill or receipt. Whenever necessary, provide a supporting statement or explanation of cost.
Equipment	Agency Owed Equipment: state agency may be eligible for the use of owned equipment when in support of the ERC operation. To assist in the reimbursement process, you may use the latest FEMA’s Schedule of Equipment Rates. ACF will not reimburse for loss of equipment. Donated labor, equipment, and/or materials that are not usually paid may not be reimbursed. Equipment that is damaged during its utilization at the ERC, must be reported immediately to the designated ACF staff, and may be eligible for reimbursement. Rented Equipment: the state may use rented equipment. Rented equipment will require ACF prior approval. During an activation of the state SERP, to request approval, send a written request to the ACF designated staff stating (1) reason for the request, (2) type of equipment, (3) cost per hour or arranged total cost, and (4) other costs that might be associated with the use of this rental equipment.	State may use FEMA’s Schedule of Equipment Rates as guidance for costs reimbursement. The damage must be documented along with sufficient supporting documentation such as video and/or photographs. If the documentation is not comprehensive, detailed and accurate, portions of the claim and possibly the entire claim may be disallowed. State may utilize the FEMA’s Rented Equipment Summary Record form. In addition, provide a copy of the rental agreement and/or other applicable receipts with your claim
escort services for unaccompanied Minors and mentally or phusically disabled adults	Escort services, not available through OMEGA, are generally eligible for reimbursement. Only eligible repatriates will be provided with this service. Escort services will only be provided based on need and will require authorization from the designated ERC Federal Emergency Repatriation Branch Supervisor.	Indicate the need for escort services on the HHS Emergency and Group Assessment Form, Part V. In addition, provide receipts and/or an escort service bill. In addition, a copy of the repatriate’s HHS Emergency and Group Assessment Form, and HHS Repayment Agreement Form should accompany the claim. With the claim, provide a summary of the type and number of individuals. For instance, 5 escorts were arranged- 3 for minors and 2 for mentally disabled adults.
Shelter	Temporary Congregate Shelter: Any private or public facility that provides short term lodging in an aggregate capacity for evacuees to sleep and/or rest while waiting for their onward travel to final destination. Examples include schools, stadiums, churches, etc. If military facilities are utilized, ACF will work with DOD to make the arrangements. State may need to operate the congregate shelter at military facilities. Transitional Shelter. Any private or public facility that, by design, provides a short-term lodging function. Examples include hotels and motels. Reimbursement will only be given for eligible repatriates. Accommodation will only be provided for one day, or until onward travel is secured. ACF will work with the state upon activation of the SERP to discuss the number of transitional shelters or rooms that might be needed. Other type of shelter accommodation.	Provide a copy of the contract, agreement, and/or rental document showing the total cost per temporary congregate shelter. Reimbursement will be provided per eligible repatriates’ reasonable lodging accommodation. States are to submit a copy of the receipt per eligible repatriate. Receipts can be in the form of a voucher signed by the eligible repatriate. In addition, a copy of the repatriate’s HHS Emergency and Group Assessment Form, and HHS Repayment Agreement Form must accompany the claim. For the other category, documentation may include bills, receipts, agreements, etc.
Service Animals	ACF generally reimburses for the cost associated to immediate temporary emergency care of service animals of eligible repatriates. Owners must approve the services.	States are to submit detailed bill of the temporary emergency aid provided to service animals. In addition, provide documentation showing owner’s approval of services and/or expenses. In addition, a copy of the repatriate’s HHS Emergency and Group Assessment Form, and HHS Repayment Agreement Form must accompany the claim.
Staff Time	Regular state employees performing direct support of ERC operations can generally request reimbursement for the actual hours worked beyond the regular duty time (either overtime, regular time hours, comp time). However, the straight-time pay for regular duty hours of these employees is not eligible for reimbursement. In addition, work performed must be reasonable and required to support the ERC. Standby time is not eligible for reimbursement. All payments must be in accordance with state policies and rates established for disaster response prior to the emergency repatriation. Donated labor, equipment, and/or materials that are not usually paid, may not be reimbursed. ACF will not be liable for any incident or accident occurring during the staff working hours. State must ensure that claims for staff time are not also covered by other Federal programs or funds.	State may utilize FEMA’s force account labor summary record form, and FEMA’s fringe benefit rate sheet form to provide the individual staff information.
Supplies	Reasonable and cost efficient resources needed to carry out the operation. Includes paper, pens, sharpeners, markers, staplers, tablets, name tags, tape, clipboards, calculators, and other things.	Provide receipts and/or other applicable documentation.
Transportation	Onward travel to final destination can only be provided to eligible repatriates. Transportation expenses not covered by ACF designated travel agency will generally be reimbursed. Congregate transportation such as arrangements from and/or to the ERC, shelter, etc. States should utilize the most cost-effective mechanism of transportation. The use of state-owned vehicle, such as buses, to support the ERC and/or provide services to repatriates, will generally be reimbursed. For ERC staff transportation, states should follow established state emergency practices.	Bill or copies of receipts. In addition, a copy of the repatriate’s HHS Emergency and Group Assessment Form, and HHS Repayment Agreement Form must accompany the claim. Copy of the bill and/or receipt. 3. Reimbursement will be made in accordance with policies and rates established by state during disasters. Such policies and rates should be established prior to an activation of the SERP. Provide copies of all applicable receipts, and if necessary state policies.
Other Costs or incidental expenses (specify)	Identify other costs by category and provide a description. During an event, the ERC ACF designated staff will assist with determinations of reasonable and allowable expenses. Prior to an emergency, the state can contact ACF for more information. Other costs may include but are not limited to: Services purchased from another agency, public or voluntary, as approved by the authorized ACF staff. A statement justifying the expenditure must be attached as well as the name of the ACF authorizing official and the date of the authorization of cost(s). Administrative costs not already included within the previous expenditures. Substantiation of claim must be attached.	Provide copies of receipts, bills, agreements, and/or other supporting documentation. Interpreters’ cost will be provided separate from translation services costs. If materials are translated, please provide electronic copies to ACF designated staff person.

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