| Department of Health and Human Services |
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OMB N0. XXXX-XXXX |
| Administration for Children and Families |
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Approval Expires X/X/XX |
| OFFICE OF REFUGEE RESETTLEMENT |
| ORR-1 CASH AND MEDICAL ASSISTANCE PROGRAM ESTIMATES |
| Grantee: ________________ |
___________________________________________________________ |
Federal Fiscal Year: |
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| 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 |
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| (b) RCA Administration |
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| (c) Subtotal |
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| 2. Refugee Medical Assistance (RMA) |
(a) RMA Recipient Costs |
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| (b) RMA Administration |
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| (c) Medical Screening/2 |
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| (d) Medical Screening Administration/2 |
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| (e) Subtotal |
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| 3. Unaccompanied Refugee Minors (URM) |
(a) Services for URMs |
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| (b) URM Program Administration |
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| (c) Subtotal |
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| 4. Administration - Program Coordination and Planning/3 |
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| 5. Total Administration/4 |
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| 6. Total Estimate/5 |
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| Signature of Approving Official |
Name and Title of Approving Official |
Date Report Submitted: |
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| Telephone Number: |
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E-mail Address: |
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| 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. |
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| 2/ Include only medical screening and medical screening administration costs paid through RMA. |
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| 3/ In accordance with 45 CFR 400.13c. |
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| 4/ Total Administration equals sum of lines 1(b), 2(b), 2(d), 3(b), and 4 of column D. |
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| 5/ Total Estimate equals sum of lines 1(c), 2(e), 3(c), and 5 of column D. |
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