Orr-2

OFFICE OF REFUGEE RESETTLEMENT CASH AND MEDICAL ASSISTANCE PROGRAM ORR-2 QUARTERLY REPORT ON EXPENDITURES AND OBLIGATIONS

OMB 0970-0407 Expires XX/XX/XXXX

1 Federal Agency and Organization Element to Which Report is Submitted

2. Grant Document/Award Number

3. EIN

4. Grantee Recipient Organization Name and Address

Grantee Name 2

Address Line 1

Address Line 2

City

State

Zip Code

Zip Ext.

5a. Project/Grant Period Start Date:

5b. Project/Grant Period End Date:

6a. Reporting Period Start Date:

6b. Reporting Period End Date:

7. Final Report? (Yes or No)

Cash and Medical Assistance Program Components (Column A)

Total Cumulative Expenditures (Column B)

Total Cumulative Unliquidated Obligations (Column C)

Total Expenditures and Unliquidated Obligations (Column D)

Federal Funds Authorized (Column E)

Unobligated Balance (Column F)

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

(d) Medical Screening Administration

(e) Subtotal

3. Unaccompanied Refugee Minors (URM)

(a) Services for URMs

(b) URM Program Administration

(c) Subtotal

4. Administration - Planning and Coordination

5. Total Administration

6. Total

7. Remarks:

Certification: I certify that, to the best of my knowledge, all expenditures and obligations are for the purpose set forth in the award documents.

8. Name and Title of Approving Official

9. Telephone Number

10. Email Address

11. Signature of Approving Official

12. Date Report Submitted