Form 1 Non-emergency Monthly Financial Statement Form

OMB Control No: 0970-0474

Expiration date: 03/31/2019

DEPARTMENT OF HEALTH & HUMAN SERVICES

Administration for Children and Families (ACF)

U.S. REPATRIATION PROGRAM

Non-Emergency Monthly Financial Statement Form

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

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

Case Name: List First, Last, middle initial

Last 4 of the SSN

Case Number Do you recommend a loan waiver or deferral? Yes No

3. Reason for Repatriation

□ Destitution

□ Mental Illness

□ International Crisis/Emergency Repatriation

□ Medical Illness (Diagnosis, if known)

□ Other

3. Composition: total number

Adults:

Minors:

Female:

Males:

3. This report covers the following period: MM/DD/YYYY

From: ______/______/______ To: ______/______/_____

Repatriate’s Current Address: Telephone:___________________________E-mail:________________________________________

(9) Is this case closed? Y es N o

( 10) Check the type of claim I nitial I nterim F inal Cancel/Refund

(11) Expenditures: information should include actual costs, NO estimates

Cash Assistance	$	Food	$
Transportation	$	Administrative Cost	$
Hospital	$	Other (specify)	$
Other Medical Facility	$	Other (specify)	$
Children Services	$	Other(specify)	$
Escort	$	Other (specify)	$
Temporary Billeting/Shelter	$	Grand Total	$

(12) 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 Name			Address-Telephone - e-mail - fax
Signature/ Print of Agency Official				Date

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. Personal information provided on this form may only be disclosed for program purposes or under the conditions prescribe in 45 CFR 211.14 or 212.9. 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”

OMB Control No: 0970-0474

Expiration date: 03/31/2019

Administration for Children and Families (ACF)

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

U.S. REPATRIATION PROGRAM

Non-Emergency Monthly Financial Statement Form

General Instructions

Purpose: A single form will be used by the state agency and/or authorized ACF providers to report expenditures and claim reimbursement for assistance furnished to individual repatriation cases referred by ACF or its grantee in the United States (U.S.) contingent to the provisions found under the Public Law 86-571 and/or Public Law 87-64, as amended, and policies issued thereunder. This form will be used for single cases unless or until the volume and nature of the cases assisted in any State is such that group reporting is indicated.

General: This form should be completed by designated state agencies and authorized ACF providers to request reimbursement of reasonable and allowable costs incurred as a result of the temporary assistance provided in the U.S. citizens and their dependents after their Department of State (DOS) repatriation from overseas. By completing this form the signatory confirms that identified expenditures have been made in accordance with 45 C.F.R. 211 and 45 CFR 212, and procedures prescribed for the U.S. Repatriation Program (Program). Reimbursement is contingent upon availability of the U.S. Repatriation Program (Program) funds.

When to submit a claim: Claims are to be submitted monthly, by the end of the month and no later than 15 days after the close of the month. Signed form with supporting documentation should be sent to the designated ACF staff and/or grantee, with a transmittal letter (see below). If the claim cannot be submitted within the 15-day grace period, the state should notify ACF or designated grantee regarding claims expected to be submitted during the preceding month. This prompt notification of estimated costs is critical and necessary in order to ensure the claim will be considered when received.

Instructions for preparing this form: reimbursement is contingent upon proper and timely submission of a complete financial claim, which included necessary supporting documentation (e.g. copies of receipts, signed vouches, and case management notes).

1. Enter the repatriates’ information. One case may include a person or the members of a family.

2. Enter the last 4 digits of the Social Security Number per repatriate.

3. Case number: use the case number listed on the initial referral

4. Check whether you recommend a repatriation waiver and/or deferral of the loan amount. If you check yes, ACF and/or designee will notify the repatriate and initiate the internal waiver/deferral investigative process.

5. Check the reason for repatriation. This information is provided within the referral. You can check one or more.

6. Indicate the composition of this case by entering the total number of adults and minors included in this form. In addition, indicate how many repatriates are female vs. males.

7. Indicate the period in which the state is claiming a cost.

8. Provide the most updated repatriate’s contact information, including the address, telephone, and e-mail, if available.

9. Case close: enter “Y” for yes or “N” for No. Once a repatriate has their immediate needs met, the case should be closed. Prompt notification of closure should be provided in writing (e.g. via e-mail) to ACF or its designated agency. You should not wait until this form is completed to notify ACF or its designated agency that a case has been closed.

10. Type of claim: check the box that correlates with the type of claim submitted per case

    1. Initial Claim: if this is the first claim submitted by the agency on this case

    2. Interim Claim: if the agency has submitted a previous claim on this case and expects to submit further claims.

    3. Final Claim: if this is the last claim the agency will submit on this case.

    4. Cancelation and refunds: if any item claimed as an expenditure in a previous month is later cancelled, voided, or refunded (e.g. not needed or changed in amount), it must be reported as a minus (-) expenditure and deducted from the claim. 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 for reimbursement.

11. Expenditures include total amount on temporary assistance and administrative costs per category. Claimed expenditures should be on an as-paid basis (e.g. checks issued) during the reporting period. All expenses should be reasonable, allowable, and allocable. Reimbursement is contingent upon available resources.

Temporary assistance is defined by 42 U.S.C. 1313 as money payments, medical care, temporary shelter, transportation, and other goods and services necessary for the health or welfare of individuals (including guidance, counseling, and other welfare services), furnished to U.S. citizens and their dependents for up to 90 days. Guidance has been provided regarding temporary assistance and how and when to provide these temporary services. For more information regarding temporary assistance, please look at available repatriation program manuals and guidelines or contact ACF or its designated agency. Please see the following information regarding potential expenditures:

1. Transportation: most cost efficient expense directly associated with in-state repatriate’ necessary travel. For instance from port of entry (POE) to resettlement place (e.g. shelter). Supporting documentation must be attached (e.g. signed voucher for bus ticket, taxi receipt).

2. Hospital: Hospital bills may be reimbursed for services provided to eligible repatriates, when not covered by other means. If other means are available but do not cover 100% of the bill, generally the Program will not pay for the uncovered expenses. For covered expenses, the Program will follow the Medicaid and/or Medicare process and rates.

3. Nursing Home or other authorized facility (e.g. Assisted Living Facility): amount paid for the care of eligible repatriates. Specify daily or monthly rate, whichever is applicable. Also follow description provided under “Hospital.”

4. Other Medical: most cost efficient expense for medical costs not covered under bullets letter c and d. It may include prescribed medications. Supporting documentation, such as a copy of the paid medical receipt is required.

5. Children services: expenses associated with the care of minors. Not including minors who have been under the care of Child Protective Services.

6. Escort services: This service must be pre-approved by authorized ACF staff.

7. Cash: use TANF rates for the amount to be disbursed to a repatriate. Agencies are to evaluate the repatriates’ needs for cash prior to issuing the check. In addition, costs associated with other expenses (e.g. transportation, temporary shelter, clothes) may be deducted from designated cash amount. Signed vouchers and/or copies of the paid check can serve as supporting documentation.

8. Temporary Billeting/Shelter: cost for temporary and reasonable shelter accommodation, whenever public shelters and/or other housing assistance programs are not available to the repatriates.

9. Vocational training: cost efficient expense used to assist the repatriate in obtaining certain minimum required job skills (e.g. GED). It does not cover long term education or college (including technical school) degrees. It is pre-approved by ACF.

10. Food: expenses associated with repatriate’s temporary food supply.

11. Other: temporary assistance expense not listed above. Specify and provide supporting documentation.

12. Administrative: staff expenses directly associated with the provision of temporary services to eligible repatriates. Supporting statements (e.g. case workers’ notes) and actual bills or receipts (e.g. parking receipt, taxi) must accompany the claim. Training and/or tips are not considered administrative costs.

12. Enter the name of the agency that will be receiving reimbursement from ACF. Provide reliable contact information for the person with authority to submit this claim on behalf of the agency. The signatory has the authority to certify that the state and/or service provider accepts responsibility for the correctness of the claim even though the expenditures were actually incurred by a different jurisdiction including a local jurisdiction of the state.

Document maintenance: case records, fiscal record supporting expenditures, including vendor bills invoices, vouchers, receipts, and cleared checks will be maintained by the agency and identified for audit purposes.

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