U.S. Repatriation Program Non-Emergency Monthly Financial Statement Form

Form RR-04

Publication Date: January 8, 2020

A single Non-Emergency Monthly Financial Statement 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.

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.

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).