DOE F 540.3 Weatherization Assistance Program Quarterly Program Repo

DOE F 540.3
(08/05)

U.S. Department of Energy
WEATHERIZATION ASSISTANCE PROGRAM
QUARTERLY PROGRAM REPORT

State: __________________

Budget period:

/

/ - /

/

OMB Control No. 1910-5127
Expiration Date: 6/30/08

Grant Number: __________________

I. GRANT OUTLAYS – FUNDS SUBJECT TO DOE PROGRAM RULES (rounded to the nearest dollar)
Reporting Period
Quarter

/ - /
Q1

/ - /
Q2

/ - /
Q3

/ - /
Q4

Total
To Date

A. OUTLAYS BY FUND SOURCE
DOE
Other funds included in grant budget, section A

Total Grant Outlays
B. OUTLAYS BY FUNCTION
Grantee Administration
Subgrantee Administration
Grantee T&TA
Subgrantee T&TA
Program Operations Total
Health and Safety
Vehicles and Equipment – Acquisition Cost*
Liability Insurance
Leveraging
Financial Audits

Total Grant Outlays
Vehicles and Equipment – Amortized Cost*

Notes:

Total grant outlays must equal outlays reported on the Financial Status Report, line 10.d.
* Acquisition (actual cost to purchase) vehicle and equipment costs must be included on this form and are used to match net outlays on
the FSR. Amortized vehicle and equipment costs are used to calculate the average cost per unit.

DOE F 540.3
(08/05)

U.S. Department of Energy
WEATHERIZATION ASSISTANCE PROGRAM
QUARTERLY PROGRAM REPORT

State: __________________

Budget period:

/

/ - /

/

Grant Number: __________________

II. GRANT PRODUCTION
Quarter

Q1

A. TOTAL ANNUAL ENERGY SAVINGS (final report only)
B. DOE UNITS* (includes other funds if included in DOE budget)
1. UNITS BY TYPE
Owner-Occupied Single Family Site Built
Single-Family Rental Site Built
Multi-Family (5 or more units per building)
Owner-Occupied Mobile Home
Renter-Occupied Mobile Home
Shelter
2. UNITS BY PRIMARY HEATING FUEL**
Natural Gas
Fuel Oil
Electricity
Propane/LPG
Kerosene
Wood
Other
3. UNITS BY OCCUPANCY
Elderly-Occupied
Disabled-Occupied
Native American-Occupied
Children-Occupied
High Residential Energy User
Household with a High Energy Burden
4. OTHER UNIT CATEGORIES
Reweatherized Total
C. TOTAL PEOPLE ASSISTED WITH GRANT FUNDS*
(includes other funds if included in DOE budget)

Elderly
Persons with Disabilities
Native Americans
Children
D. Leveraged Units (units completed with other funds that are not
included in DOE budget, any part of the definition of a DOE unit
has been met)
* Do not include reweatherized units in sections B.1, B.2, B.3 and C.
** “Primary Heating Fuel” is the fuel that provides the most space heat in the home.

Q2

Q3

Q4

Total
To Date

DOE F 540.3
(08/05)

III. COMMENTS

Submitted by _________________________________________________________________ Date __________________________
Typed name __________________________________________________________________
Title ________________________________________________________________________

DOE F 540.3

OMB Control No. 1910-5127

(08/05)

Expiration Date: 6/30/08

OMB Burden Disclosure Statement
Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of the Chief Information Officer, Records Management Division,
IM-11, Paperwork Reduction Project (1910-5127), U.S. Department of Energy, 19901 Germantown Road, Germantown, MD
20874 and to the Office of Management and Budget, OIRA, Paperwork Reduction Project (1910-5127), Washington, DC 20503.

U.S. Department of Energy
WEATHERIZATION ASSISTANCE PROGRAM
QUARTERLY PROGRAM REPORT
INSTRUCTIONS
The Quarterly Program Report format is designed to gather production and expenditure data. This report is to be submitted quarterly
to the applicable Department of Energy Regional Office 30 days after the end of the reporting period.
State:
Budget period:
Grant number:
Reporting period:
I.

Name of state or tribal organization submitting the report.
The starting and ending dates (mm/dd/yy)for the budget period for the WAP program year.
The seven-digit Federal identification number assigned to the grant (R999999).
The beginning and ending dates (mm/dd) for the quarter reported.

GRANT OUTLAYS – FUNDS SUBJECT TO DOE PROGRAM RULES
A.

By fund source: Outlays this quarter and program year to date for
1. DOE funds
2. All other funds listed in the grant budget, Section A, including PVE (Exxon, Stripper-Well, etc.), LIHEAP, state,
local, and private funds that are part of the approved DOE grant budget.

B.

By function: Outlays this quarter and program year to date for each function in the DOE grant budget, section B. Total
must equal total in A.2 above.
1. Acquisition (actual) vehicle and equipment costs are used to match net outlays in FSR. Authorized vehicle and
equipment costs are used to calculate the average cost per unit.

II. GRANT PRODUCTION
Enter figures only for the quarter being reported except to correct previous quarter information. Include reweatherized
and low cost/no cost units only in section B.4.
A.

Estimated Total Annual Energy Savings Estimate of total annual energy saved as a result of weatherization work. Include
in final report only.

B.

DOE units completed this quarter with all funds included in the approved DOE grant budget, all sources.
1. Units by type: Number completed this quarter by type specified. The sum should equal total units completed with
funds in the approved DOE budget. A completed unit in a building containing five or more units should be reported
as a Multi-Family unit. A completed unit in a building containing four units or less should be reported under one of
two Single-Family categories. For example, if both units in a renter-occupied duplex are weatherized, they should be
reported as two Single-Family Rental Site Built completions.
2. Units by primary heating fuel. Number of units completed by category of primary heating fuel. Primary heating fuel
is the fuel that provides the most space heat in the home.
3. Units by occupant: Number of units completed by category of occupant. The sum will not equal total units completed.
4. Other categories: Units reweatherized.

C.

Persons assisted with funds included in the DOE grant budget, all sources: Total and by category. Sum of persons by
category will not equal total persons assisted.

D.

Leveraged units completed with other funds not included in the DOE budget provided any part of the definition of a DOE
unit has been met.

III. COMMENTS
Include here any additional information needed to clarify grant outlays and production reported this quarter.
Submitted by Signature of the person submitting the report.
Date signed.
Typed name and title of the submitter.