1 Orr-1

Refugee Resettlement Program Estimates: CMA ORR-1

ORR-1.xlsx

Refugee Resettlement Program Estimates: CMA

OMB: 0970-0030

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Department of Health and Human Services


OMB N0. 0970-0030
Administration for Children and Families


Approval Expires XX-XX-20XX
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/ Annualized monthly costs for rows 1(a), 2(a), 2(c), and 3(a), in column B are multiplied by the figure in column C and then multiplied 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 4 of column D.



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