1 Emergency Repatriation Reimbursement Request

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

U.S. REPATRIATION PROGRAM
EMERGENCY REPATRIATION REIMBURSEMENT REQUEST

SECTION I: AGENCY AND INCIDENT INFORMATION
1. Name of Agency / Address (street, city, state, zip)				2. Type of Agency  State  Federal ¨ Authorized Support Organization				3. Incident Name and Date Name From To
4. Nature of Claim  Partial #__  Final ¨ Revision to claim submitted on ____________		5. Emergency Repatriation Center (ERC) Information ¨ Airport ______________________________________________________________ ¨ Military Base _________________________________________________________ ¨ Other _______________________________________________________________ TOTAL # of ERCs ___
SECTION II: EXPENDITURES
6. List expenditures in the table below.
Expenditure	Total		Expenditure	Total		Expenditure			Total
Airport Cost			Staff Overtime			Temporary Lodging
ERC Space			Other Staff Costs			Planning, Training, Exercises
ERC Safety & Security			Money Payments			Other (specify)
Equipment			Food (Repatriate)			Other (specify)
Supplies			Emergency Medical Services			Other (specify)
Transportation (ERC)			Transportation (Repatriate)			Other (specify)
7. Additional Information
SECTION III: 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. (US. Code, Title 18, section 1001)
8. Name and Title of Agency Official Name Title					9. Contact Information Telephone Email
10. Signature							11. Date (MM/DD/YYYY)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is for states to request reimbursement for costs incurred as a result of an emergency repatriation or an approved planning, training, or exercise activity. 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 an emergency repatriation (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: For designated state agencies and OHSEPR- authorized support agencies to request reimbursement for reasonable, allowable, and allocable costs incurred as a result of (1) OHSEPR activation of the State Emergency Repatriation Plan (SERP); (2) Agreement with OHSEPR to support an emergency repatriation operation; or (3) an OHSEPR-approved planning, training, or exercise activity in support of the U.S. Repatriation Program.

Who Should Complete this Form: An authorized representative of the designated state agency or of the OHSEPR-authorized support agency. Only one representative may submit per state.

When to Submit: Reimbursement requests may be submitted on an ongoing basis, but must be submitted no later than 180 days following the deactivation notice date for an emergency repatriation operation or the completion date of the planning, training, exercise activity. If the reimbursement request cannot be submitted within the 180-day period, the state or support agency should submit timely written notification to ACF providing an explanation and requesting an extension.

What to Include:

1. Use this form as a summary sheet to submit a full or partial claim with reasonable, allowable, and allocable expenses incurred (not estimated) by state agencies and/or authorized support agencies. Federal agencies’ costs should not be included with the state claim.

2. Reimbursement must be for actual costs and not estimates. Reimbursement is based on supporting documentation (e.g., receipts, signed vouchers, invoices, etc.) which must be sufficient to help the claimant meet its burden of demonstrating the allowability of the cost. Documentation should be provided for both administrative costs and temporary assistance expenses. See instructions below, ACF’s Emergency Repatriation Information Memorandum on its website, and 45 CFR Part 75 for more information regarding required documentation.

Where to Send: Requests should be sent to the above address or via e-mail to the designated ACF staff and OHSEPR-AF@acf.hhs.gov.

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.”

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.

If any item claimed as expenditure is paid and later canceled, voided, or refunded 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.

For audit purposes, the state or agency submitting this form must maintain all fiscal records supporting expenditures on this form, including vendor bills, invoices, vouchers receipts, and cleared checks.

SPECIFIC INSTRUCTIONS

SECTION I: AGENCY AND INCIDENT INFORMATION

Item 1. Name of Agency/ Address. Provide Agency name and physical address.

Item 2. Type of Agency. Check one or check more than one if a state is submitting for an Authorized Support Organization.

Item 3. Incident Name and Date. Enter the name of the repatriation mission and its activation and closing dates.

Item 4. Nature of Claim. Indicate if this submission is a portion of the final amount anticipated to be billed, the final bill for the mission, or a revision of a previously submitted form. If this is a partial claim, indicate if this is the first, second, third, etc. If this is a revision, please include the date and a copy of the previously submitted form.

Item 5. ERC Information. Enter the city and state/ physical location(s) and address(es) for the ERC(s) in your state. Include the total number of ERCs.

SECTION II: EXPENDITURES

Item 6. List expenditures in the table provided. List expenditure totals according to type for the period provided. Include supporting documentation when submitting this claim such as cost pre-approvals and itemized receipts. Provide any additional information in the space provided, as needed.

Airport Costs are those associated with the establishment and operation of the ERC at the airport. Provide an itemized bill and supporting documentation.

ERC Space is the physical location to provide services to repatriates. 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 OHSEPR activation of the SERP but prior to the first plane arrival. Please also be aware of construction and repair cost limitations in 45 CFR Part 75.

Safety & Security associated with keeping the ERC and personnel safe and secure. Provide necessary receipts. See the staff overtime section of this document for more information.

Equipment. Provide a copy of the rental agreement for the equipment and/or other applicable receipts with your claim. If the documentation is not comprehensive, detailed, and accurate, portions or the entirety of the claim may be disallowed.

Supplies necessary to carry out the operation. Provide all supporting documentation.

Transportation (ERC). For ground transportation between the airport and the ERC for repatriates and staff. Provide copies of all applicable receipts, and, if necessary, state policies.

Money Payments. For cash assistance provided to eligible repatriates, states must submit the following documents with their claims: receipts for cash cards and proof of cash amount provided to the repatriate (e.g., copy of signed voucher).

Food (Repatriate). Provide an itemized bill and copies of receipts.

Emergency Medical Services. (1) For Emergency Medical Services, provide an itemized bill of all costs. Whenever necessary, provide a supporting statement or explanation of cost. Indicate the total number of repatriates assisted. For unusual expenses, request prior federal approval and when authorized attach a statement to justify the expenditure.

(2) For pharmaceuticals, provide an itemized bill with associated costs, including costs allocable to each individual repatriate. Provide a supporting statement or explanation of cost. Indicate the total number of repatriates who received pharmaceuticals at the ERC and the type. For instance, 50 received some type of pharmaceuticals. Out of the 50, 30 received insulin, 20 received painkillers (include name of painkillers).

(3) For ambulances, use current CMS reimbursement rates in the locality as guidance. Provide the total number of ambulances used during the event and total number of repatriates who received transportation assistance.

(4) For hospitalizations, 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 the insurance company with explanation for the denial can be used as supporting documentation. When requesting reimbursement from the Program, itemized hospital bills should be calculated at a Medicare or Medicaid 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.

Temporary Lodging. When applicable, states should submit a copy of the receipt for each eligible repatriate. Receipts can be in the form of a voucher signed by the eligible repatriate. For hotel room blocks, states should submit the OHSEPR pre-approval indicating the number of rooms and length of time.

(1) For temporary congregate shelters, provide a copy of the contract, agreement, and/or rental document showing the total cost per temporary congregate shelter.

(2) For transitional shelters, such as a hotel, reimbursement will be provided per eligible repatriates’ reasonable lodging accommodation.

(3) For other types of shelter accommodations, documentation may include bills, receipts, or agreements.

Staff Overtime. Provide supporting documentation to include staff information on hours worked and labor rates. Provide both individual and summary level information.

Planning, Training & Exercises. Provide copies of OHSEPR pre-approval, receipts, bills, agreements, and/or other supporting documentation.

Other. Provide copies of receipts, bills, agreements, and/or other supporting documentation.

Identify other costs by category and provide a description. During a repatriation mission, the OHSEPR designated staff will assist with determinations of reasonable, allowable, and allocable expenses. Prior to an emergency repatriation operation, the state can contact OHSEPR for more information. Other costs may include but are not limited to the following:

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 in other expenditures.

Item 7. Additional Information. Use this space to provide additional information, if necessary.

SECTION III: SIGNATURE

Item 8. Name and Title of Agency Official. Provide full name and title of the agency official signing this form.

Item 9. Contact Information. Provide the contact information for the agency official signing this form.

Item 10. Signature. The agency official must sign in order for HHS/ACF to process the form.

Item 11. Date (MM/DD/YYYY). Provide the date the form is signed. Format as two-digit month and day and four-digit year.

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