Long Format for Assisted

Low Income Home Energy Assistance Program (LIHEAP) Household Report

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0060 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Long Format for Assisted Form and Instruction
1 LIHEAP Long Format for Assisted hhsrptst12_long form.xls Form and Instruction

Information Collection (IC) Details

IC Title:	Long Format for Assisted	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 96.82

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	LIHEAP Long Format for Assisted	hhsrptst12_long form.xls		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	1,300	1,300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.