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LIHEAP GRANTEE SURVEY EDIT PAGE - SAMPLE FORMAT |
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Grantee: |
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FFY: 2006 |
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Sources of Funds |
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Block |
Emergency |
Petroleum Violation |
Obligated |
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Grant |
Contingency |
Escrow Funds |
Leveraging |
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Allotment |
Funds* |
(PVE) |
Funds |
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*Note: Contingency Funds are the sum of items 2 and 3 under Sources of |
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$0 |
$0 |
$0 |
$0 |
Funds minus item 6 under Uses of Funds |
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Base Calculations for Sources of Funds--SUMs 1 & 2 |
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SUM 1 = Block grant $ + emergency contingency $ + PVE |
$0 |
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SUM 2 = Block grant $ + emergency contingency $ + PVE $ + obligated leveraging $ |
$0 |
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| 1. |
Sources - Uses of Funds |
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Total |
Total |
Total Sources - Total Uses |
Balanced? |
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Sources** |
Uses** |
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**Note: Totals from pages 1 and 2 of the survey. |
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$0 |
$0 |
$0 |
YES |
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| 2. |
Weatherization (No greater than 15% of SUM 1) |
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Do weatherization $'s include obligated leveraging funds? |
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Yes |
? |
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Weatherization |
SUM |
% |
At or below 15% |
No |
? |
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Assistance |
1 |
Weatherization/Sum 1 |
of SUM 1? |
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Did your State receive a 25% waiver from HHS? |
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$0 |
$0 |
0% |
YES |
Yes |
? |
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No |
? |
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| 3. |
Carryover of Unobligated Funds (No greater than 10% of SUM 1) |
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Carryover to |
SUM |
% |
At or below 10% |
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Next Fiscal Year |
1 |
Carryover/Sum |
of SUM 1? |
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$0 |
$0 |
0% |
YES |
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| 4. |
Administrative/Planning Costs (No greater than 10% of SUM 2) |
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Administrative & |
SUM |
% |
At or below 10% |
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Planning Costs |
2 |
Administrative & Planning/Sum 2 |
of SUM 2? |
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$0 |
$0 |
0% |
YES |
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| 5. |
Assurance 16 Costs (No greater than 5% of SUM 1) |
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Assurance 16 |
SUM |
% |
At or below 5% |
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Costs |
1 |
Assurance 16 Costs/Sum 1 |
of SUM 1? |
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$0 |
$0 |
0% |
YES |
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| 6. |
Leveraging Activities (No greater than 0.08% of SUM 1 or $35,000) |
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At or below |
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Leveraging |
SUM |
Max. of $35,000 or |
$35,000 or |
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Activities |
1 |
SUM 1 *.08% |
SUM 1 *.08% |
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$0 |
$0 |
$35,000 |
YES |
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| 7. |
4-Person Household Income Cutoffs => 110% of 2005 HHS Poverty Guidelines |
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Heating |
Cooling |
Winter Crisis |
Summer Crisis |
Yr. Round Crisis |
a. Other Crisis |
b. Other Crisis |
c. Other Crisis |
Weatherization |
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4-Person Dollar Cutoff |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
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HHS Poverty Guidelines |
$19,350 |
$19,350 |
$19,350 |
$19,350 |
$19,350 |
$19,350 |
$19,350 |
$19,350 |
$19,350 |
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% of Poverty Guidelines |
0% |
0% |
0% |
0% |
0% |
0% |
0% |
0% |
0% |
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= or Greater Than 110% |
NO |
NO |
NO |
NO |
NO |
NO |
NO |
NO |
NO |
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NOTES: |
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