Form RR-04 Routine Repatriation Reimbursement Request

OMB Control No:	0970-0474
Expiration Date:
Estimated Burden:	20 minutes

U.S. REPATRIATION PROGRAM
ROUTINE REPATRIATION REIMBURSEMENT REQUEST

SECTION I: AGENCY INFORMATION
1. Agency Name and Address								2. Type of Agency ¨ State ¨ Local Service Provider
SECTION II: REPATRIATE INFORMATION
3. Case Number	4. Case Status ¨ Open ¨ Closed			5. Claim Request Period MM/DD/YYYY From: ___ /___ /___ To: ___ /___ /___				6. Type of Claim ¨ Initial ¨ Interim ¨ Final ¨ Cancel / Refund
7. Repatriate Name			8. Repatriate SSN				9. Dependent(s) Name 1. 2. 3. 4. 5.			10. Case Composition Total Number: Adults: Minors:
11. Repatriate Current Address						12. Repatriate’s Contact Information Telephone Email
SECTION III: EXPENDITURES
13. Costs for the Repatriate(s)
Expenditures		Total			Expenditures				Total
Money Payments					Administrative Costs
Medical Care					Other (specify):
Temporary Lodging					Other (specify):
Transportation					Other (specify):
Escort Services					Total
14. Additional Comments
SECTION IV: SIGNATURE
By signing this document, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that any false, fictious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, title 18, section 1001). I also certify that the identified expenditures have been made in accordance with 42 U.S.C. 1313, 45 CFR 211, 45 CFR 212, 45 CFR Part 75 and procedures prescribed for the U.S. Repatriation Program.
15. Name and Title of Agency Official (Print) Name Title					16. Contact Information Telephone Email
17. Signature									18. Date (MM/DD/YYYY)

PAPERWORK REDUCTION ACT OF 1995 (b. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is for states to request reimbursement for providing temporary assistance under the U.S. Repatriation Program. Public reporting burden for this collection of information is estimated to average 0.3 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to obtain reimbursement for providing temporary assistance (42 U.S.C. Section 1313). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0474 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact the U.S. Repatriation Program, 330 C St. SW, Washington, D.C. 20201.

GENERAL INFORMATION

Purpose: The purpose of this form is for state and local service providers to submit reimbursement requests for providing temporary assistance to repatriates under the U.S. Repatriation Program (Public Law 86-571 and/or Public Law 87-64).

Who Should Complete this Form: This form should be completed by designated state agencies and authorized local service providers.

When to Submit: Claims are to be submitted monthly, by the end of the month and no later than 15 days after the close of the month. If the claim cannot be submitted within this timeframe, the state should notify ACF or its grantee regarding claims to be submitted during the following month. This prompt notification of estimated costs is critical and necessary for Program operations.

Where to Submit: Signed form with supporting documentation should be sent to the OHSEPR grantee.

Disclaimer: Title 18 of the United States Code 1001 states that an individual who “knowingly and willfully - (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.”

1. State agencies or local service providers may submit a single form to report expenditures and claim reimbursement for temporary assistance provided to individual repatriation cases in the United States.

2. OHSEPR will reimburse only reasonable, allowable, and allocable costs incurred as a result of temporary assistance provided in the U.S. citizens and their dependents in the United States after being returned by Department of Staten from a foreign country.

2. Reimbursement is contingent upon proper and timely submission of a complete financial claim, which includes necessary supporting documentation (e.g., copies of receipts, signed vouchers, and case management notes).

3. Reimbursement is contingent upon availability of the U.S. Repatriation Program funds and the allowability of the expenditure under 42 U.S.C. § 1313, the implementing regulations at 45 CFR Parts 211 and 212 and the general grants administration regulations at 45 CFR Part 75 particularly subpart E – Cost Principles.

SPECIFIC INSTRUCTIONS

SECTION I: AGENCY INFORMATION

Item 1. Name of Agency / Address. Provide the name of the requesting state agency and the full address including street, suite number (if applicable), city, state, and zip code.

Item 2. Type of Agency. Check all that apply.

SECTION II: REPATRIATE INFORMATION

Item 3. Case number. Provide the case number associated with this case.

Item 4. Case Status. Select one of the two boxes to indicate if the case is ‘closed’ or ‘open.’

Item 5. Claim Request Period (MM/DD/YYYY). Provide the date the case was opened and the closing date. If the case is still open, write ‘present.’

Item 6. Type of Claim. Select one of the four boxes to indicate if the request is initial, interim, final, or a cancellation/ refund.

Item 7. Repatriate Name. Provide the repatriate’s full name.

Item 8. Social Security Number. Provide the repatriate’s nine-digit social security number.

Item 9. Dependent(s). List the dependent(s) names. If there are more than 5, use a separate sheet of paper.

Item 10. Case Composition. Provide the total number of individuals in this case, including the applicant. Indicate the number of minors and adults in the space provided.

Item 11. Repatriate Current Address. Provide the repatriate’s current address.

Item 12. Repatriate’s Contact Information. Provide the best email and phone number, including area code, for the repatriate.

SECTION III: EXPENDITURES

Item 13. Costs for the Repatriate(s). Indicate the dollar amount provided to the repatriate for each type of expenditure for which the state is seeking reimbursement. Also, provide the combined total amount of expenditures. Supporting documentation is required for all expenses. If OHSEPR pre-approval was required and received, provide the appropriate documentation. Include any additional comments, as necessary, in the space provided.

Money Payments: Signed vouchers and copies of the paid check can serve as supporting documentation.

Medical Care: Provide bills and paid receipts for covered expenses.

Temporary Lodging: Provide invoice and paid receipt.

Transportation: Provide signed vouchers and receipts (e.g., signed voucher for bus ticket, taxi receipt).

Escort Services: Provide invoice, receipts, and pre-approvals from OHSEPR.

Administrative Costs: Include supporting statements, such as case workers’ notes, bills, and receipts (e.g., parking receipt, taxi).

Other: Identify type of temporary assistance. Provide supporting documentation detailing the assistance, the receipt for the paid amount, and OHSEPR pre-approvals if applicable.

Item 14. Additional Comments. Use this space to provide further information, if necessary.

SECTION IV: SIGNATURE

Item 15. Name and Title of Agency Official. Print the Agency Official’s full name and title.

Item 16. Contact Information. Provide the signatory’s email address and phone number, including area code, to be reached with any questions about this form.

Item 17. Signature. Sign in the space provided to confirm that the information provided on the document is true, complete, and accurate, and that the identified expenditures have been made in accordance with 45 CFR 211 and 45 CFR 212, and policies and procedures prescribed for the U.S. Repatriation Program.

Item 18. Date (MM/DD/YYYY). Provide the date of signature in the form of a two-digit month and day and a four-digit year.

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