Form 1 LIHEAP Household Report-Short Form

OMB Control No. 0970-0060	LIHEAP Household Report--Federal Fiscal Year 2012--Short Format			Expiration Date:
Grantee Name:			Date:
Contact Person:			Phone:
The LIHEAP Household Report-Short Format is for use by all direct-grant Indian tribes and tribal organizations. The LIHEAP Household Report-Short Format
also is for use by insular areas (with the exception of the Commonwealth of Puerto Rico). This report provides data on LIHEAP assisted households for Federal
Fiscal Year (FFY) 2012, the period of October 1, 2011 - September 30, 2012. The Report consists of the Recommended Short Format for Assisted Households
below. As the reported data are aggregated, the information in this report is not considered to be confidential.
Both the Recommended Short Format (the Excel file name is hhsrptin.xls) and the instructions on completing the LIHEAP Household Report-Short Format
(the Word file name is hhrptins.doc) can be downloaded at the Forms section of the Office of Community Services LIHEAP web site at:
www.acf.hhs.gov/programs/ocs/liheap/grantees/forms.html#household_report
The spreadsheet is page protected in order to keep the format uniform. The items requiring a response are not page protected. However, other areas of the
spreadsheet can not be modified.
	RECOMMENDED SHORT FORMAT FOR LIHEAP ASSISTED HOUSEHOLDS
	REQUIRED DATA
	Type	Number of
	of	assisted
	assistance	households
	Heating
	Cooling
	Winter/year round crisis
	Summer crisis
	Weatherization
Note: Include any notes below for (indicate which type of assistance the note is referencing).