| LIHEAP Performance Data Form for Federal Fiscal Year (FFY) 201x |
| OMB Control No. 0970-xxxx |
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| LIHEAP Grantee Survey |
| SECTION I. GRANTEE INFORMATION |
| Grantee Name: |
Date: |
Contact Person: |
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Phone Number: |
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| SECTION II. REPORTING REQUIREMENTS |
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The 50 States and the District of Columbia are required to complete the LIHEAP Grantee Survey in providing estimates of sources and uses of funds, average benefits, and the maximum income cutoff in dollars for a 4-person household as of 10/1/1x for each type of LIHEAP assistance provided in FFY 201x.
Additionally, the 50 states and the District of Columbia are required to complete the LIHEAP Performance Measurement Form. This Federal Report provides data on three required LIHEAP Performance Measures for Federal Fiscal Year (FFY) 201x, the period of October 1, 201x - September 30, 201x. The Report consists of the following sections: (1) Energy Burden Targeting, (2) Restoration of Home Energy Service, and (3) Prevention of Loss of Home Energy Service. |
| Timely response to questions on this report is mandatory. The information will be used to respond to Congressional inquiries, to calculate LIHEAP benefit targeting, and to provide Federal Fiscal Year data for the Department's annual LIHEAP Report to Congress that is required under Section 2610 of Public Law 967-35, as amended. The data are also used in measuring LIHEAP performance under the Government Performance and Results Act (GPRA) of 1993, as amended by the GPRA Modernization Act of 2010. As the reported data are aggregated, the information in this report is not considered to be confidential. |
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| SECTION III. ESTIMATED SOURCES OF LIHEAP FUNDS |
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ALL OF FFY 201x (10/1/201x TO 9/30/201x) |
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Amount Rounded to the Nearest Dollar |
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| A. All funds Except Leveraging Incentive Awards (Items 1-8) |
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| 1. FFY LIHEAP Block Grant Allotment (Net of Indian Tribal Set-Asides) |
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nicolas-cavallo:
Pre-populated & locked
$0 |
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| 2. FFY Emergency Contingency Funds (Net of Indian Tribal Set-Asides) |
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nicolas-cavallo:
Pre-populated & locked
$0 |
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| 3. LIHEAP Block Grant Funds Realloted to FFY |
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nicolas-cavallo:
Pre-populated & locked
$0 |
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| 4. Previous FFY Unobligated Emergency Contingency Funds, not Subject to 10% Carryover Limit |
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nicolas-cavallo:
Pre-populated
$0 |
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| 5. Previous FFY Unobligated Leveraging Incentive Funds, not Subject to 10% Carryover Limit |
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nicolas-cavallo:
Pre-populated
$0 |
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| 6. All Funds Carried Over From Previous FFY (except Funds in item 4 and 10 in this Section) |
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nicolas-cavallo:
Pre-populated
$0 |
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| 7. Petroleum Violation Escrow (Oil Overcharge) Funds Obligated in FFY |
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$0 |
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| 8. FFY Residential Energy Assistance Challenge (REACH) Program |
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nicolas-cavallo:
Pre-populated & locked
$0 |
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| B. Leveraging Incentive Award (Items 9-10) |
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| 9. FFY Leveraging Incentive Award obligated in next FFY |
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nicolas-cavallo:
Pre-populated & locked
$0 |
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| 10. Previous FFY Leveraging Incentive Award obligated in FFY |
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nicolas-cavallo:
Pre-populated
$0 |
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| C. Estimated Total Sources of Funds (Items 1-10) |
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| 11. Sum of Items 1-10. This should equal the sum in Section IV. Column D, Item 13. |
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nicolas-cavallo:
Calculated & locked
$0 |
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| SECTION IV. ESTIMATED USES OF LIHEAP FUNDS |
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| A. Type of LIHEAP Assistance (Items 1-4) |
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All of FFY 201x (10/1/201x) to 9/30/201x) |
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Amount Rounded to the Nearest Dollar |
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Total Funds/Awards |
Average Household Benefit |
Maximum Annual Dollar Income for 4-Person Household as of 10/1/1x |
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| 1. Heating Assistance Benefits |
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$0 |
$0 |
$0 |
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| 2. Cooling Assistance Benefits |
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$0 |
$0 |
$0 |
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| 3. Crisis Benefits by Type: |
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| a. Winter Crisis Benefits |
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$0 |
$0 |
$0 |
| b. Summer Crisis Benefits |
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$0 |
$0 |
$0 |
| c. Year-round Crisis Benefits |
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$0 |
$0 |
$0 |
| d. Other Crisis Benefits |
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nicolas-cavallo:
Locked with formula that sums sub columns to the right
$0 |
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| (1) Specify: |
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$0 |
$0 |
$0 |
| (2) Specify: |
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$0 |
$0 |
$0 |
| (3) Specify: |
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$0 |
$0 |
$0 |
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| 4. Weatherization Assistance Benefits |
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$0 |
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$0 |
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Bill Payment-Assisted Household Main Fuel |
| All Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric) |
All Households |
Electricity |
Natural Gas |
Fuel Oil |
Propane |
Other Fuels |
| 5. Average Annual Total LIHEAP Benefit per Household (including Heating, Cooling, Crisis, Supplemental Benefits) |
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| B. Other Permitted Uses of LIHEAP Funds (Items 6-14) |
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| 6. Nominal Payments |
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$0 |
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| 7. FFY Unobligated Funds (excluding funds in Items 6 & 7) Carried Over to next FFY |
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$0 |
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| 8. FFY Allowable Unobligated Emergency Contingency Funds, not Subject to 10% Carryover Limit, Obligated in next FFY |
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nicolas-cavallo:
Pre-populated
$0 |
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| 9. FFY Leveraging Incentive Award Obligated in next FFY |
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nicolas-cavallo:
Pre-populated
$0 |
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| 10. FFY Emergency Contingency Funds Obligated in next FFY |
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nicolas-cavallo:
Pre-populated
$0 |
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| 11. FFY LIHEAP Block Grant Allotment Used to Identify, Develop & Demonstrate Leveraging Incentive Activities |
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$0 |
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| 12. Assurance 16 Activities |
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$0 |
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| 13. FFY Residential Energy Assistance Challenge (REACH) Program |
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$0 |
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| 14. Administration/Planning Costs |
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$0 |
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| C. Estimated Total Uses of Funds (Items 1-4 and 6-14) |
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$0 |
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| 15. Sum of Items 1-4 and 6-14. This should equal the sum in Section III. Column D, Item 11. |
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nicolas-cavallo:
Locked with formula that adds up the column values
$0 |
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| Q1. Obligated funding for a given type of assistance in current FFY, but will serve households in the subsequent FFY |
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yes/no |
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| Q2. Average Household Benefits are estimated due to unique program operation, rather than directly calculated |
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yes/no |
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| Notes: Include any notes. Please indicate type of LIHEAP assistance and item being referenced. |
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| LIHEAP Performance Measures |
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| V. ENERGY BURDEN TARGETING |
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Bill Payment-Assisted Household Main Fuel |
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All Households |
Electricity |
Natural Gas |
Fuel Oil |
Propane |
Other Fuels |
| A. Unduplicated Number of LIHEAP Bill Payment-Assisted Households |
nicolas-cavallo:
Pre-populated & locked
0 |
nicolas-cavallo:
Pre-populated & locked
0 |
nicolas-cavallo:
Pre-populated & locked
0 |
nicolas-cavallo:
Pre-populated & locked
0 |
nicolas-cavallo:
Pre-populated & locked
0 |
nicolas-cavallo:
Pre-populated & locked
0 |
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| B. All Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric) |
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| 1. Unduplicated Number of Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric) |
0 |
0 |
0 |
0 |
0 |
0 |
| 2. Average Annual Household Income |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
| 3. Average Annual Total LIHEAP Benefit per Household (including Heating, Cooling, Crisis, Supplemental Benefits) |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
| 4. Average Annual Main Heating Fuel Bill |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
| 5. Average Annual Electricity Bill |
$0 |
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$0 |
$0 |
$0 |
$0 |
| 6. Average Annual Total Residential Energy Bill |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 7. Average Annual Burden Before Receiving LIHEAP |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 8. Average Annual Burden After Receiving LIHEAP |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 9. Average Percentage Point Change in Energy Burden |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 10. Average Percentage Reduction in Energy Burden |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
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| C. High Burden Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric) |
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| 1. Unduplicated Number of High Burden Households (Top 25%) with 12 Consecutive Months of Bill Data (Main Fuel and Electric) |
0 |
0 |
0 |
0 |
0 |
0 |
| 2. Average Annual Household Income for High Burden Households |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
| 3. Average Annual Total LIHEAP Benefit per High Burden Household (including Heating, Cooling, Crisis, Supplemental Benefits) |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
| 4. Average Annual Main Heating Fuel Bill for High Burden Households |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
| 5. Average Annual Electricity Bill for High Burden Households |
$0 |
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$0 |
$0 |
$0 |
$0 |
| 6. Average Annual Total Residential Energy Bill for High Burden Households |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 7. Average Annual Burden Before Receiving LIHEAP for High Burden Households |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 8. Average Annual Burden After Receiving LIHEAP for High Burden Households |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 9. Average Percentage Point Change in Energy Burden for High Burden Households |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
| 10. Average Percentage Reduction in Energy Burden for High Burden Households |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
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| D. Benefit Targeting Index for High Burden Households: |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
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| E. Burden Reduction Targeting Index for High Burden Households: |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
Auto-Calculated |
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| VI. RESTORATION OF HOME ENERGY SERVICE |
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Energy Source (where LIHEAP benefit was applied) |
| A. All Occurrences of LIHEAP Households that Had: |
All Occurrences |
Electricity |
Natural Gas |
Fuel Oil |
Propane |
Other Fuels |
| 1. Energy Service Restored After Disconnection |
Auto-Calculated |
0 |
0 |
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| 2. Fuel Delivered to Home that Ran Out of Fuel |
Auto-Calculated |
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0 |
0 |
0 |
| 3. Repair/Replacement of Inoperable Home Energy Equipment |
Auto-Calculated |
0 |
0 |
0 |
0 |
0 |
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| VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE |
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Energy Source (where LIHEAP benefit was applied) |
| A. All Occurrences of LIHEAP Households that Had: |
All Occurrences |
Electricity |
Natural Gas |
Fuel Oil |
Propane |
Other Fuels |
| 1. Past Due Notice or Utility Disconnect Notice |
Auto-Calculated |
0 |
0 |
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| 2. Imminent Risk of Running out of Fuel |
Auto-Calculated |
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0 |
0 |
0 |
| 3. Repair/Replacement of Operable Equipment to Prevent Imminent Home Energy Loss |
Auto-Calculated |
0 |
0 |
0 |
0 |
0 |
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| NOTES: Include any notes. |
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| VIII. CERTIFICATION FOR REQUIRED SECTIONS I. - VII. |
| 1A. I certify to the best of my knowledge and belief that this report is correct and complete for Administration and Congressional oversight the program and for the purposes set forth in the award letter. |
| 2A. Typed or Printed Name and Title of Authorized Certifying Official: |
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Date Submitted: |
| 3A. Signature of Authorized Certifying Official: (click to sign) |
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Month Day Year |
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| LIHEAP Performance Measures |
| OPTIONAL MEASURES |
| V. ENERGY BURDEN TARGETING (OPTIONAL MEASURES) |
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Bill Payment-Assisted Household Main Fuel |
| A. All Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric) |
All Households |
Electricity |
Natural Gas |
Fuel Oil |
Propane |
Other Fuels |
| 1. Average Annual Electricity Usage |
0 |
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0 |
0 |
0 |
0 |
| 2. Average Annual Main Heating Usage |
0 |
0 |
0 |
0 |
0 |
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| B. High Burden Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric) |
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| 1. Average Annual Electricity Usage for High Burden |
0 |
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0 |
0 |
0 |
0 |
| 2. Main Heating Usage for High Burden |
0 |
0 |
0 |
0 |
0 |
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| C. Unduplicated Number of LIHEAP Bill Payment-Assisted Households that Use: |
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| 1. Electricity as Supplemental Heating Fuel |
0 |
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0 |
0 |
0 |
0 |
| 2. Wood as Supplemental Heating Fuel |
0 |
0 |
0 |
0 |
0 |
0 |
| 3. Other Supplemental Heating Fuel |
0 |
0 |
0 |
0 |
0 |
0 |
| 4. Central Air Conditioning |
0 |
0 |
0 |
0 |
0 |
0 |
| 5. Window/Wall A/C (including evaporative cooler) |
0 |
0 |
0 |
0 |
0 |
0 |
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| VI. RESTORATION OF HOME ENERGY SERVICE (OPTIONAL MEASURES) |
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Energy Source |
| A. Number of All LIHEAP-Assisted Households that Had: |
All Households |
Electricity |
Natural Gas |
Fuel Oil |
Propane |
Other Fuels |
| Unduplicated Count of Restorations of Home Energy Service |
0 |
0 |
0 |
0 |
0 |
0 |
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| VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE (OPTIONAL MEASURES) |
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Energy Source |
| A. Number of All LIHEAP-Assisted Households that Had: |
All Households |
Electricity |
Natural Gas |
Fuel Oil |
Propane |
Other Fuels |
| Unduplicated Count of Preventions of Loss of Home Energy Service |
0 |
0 |
0 |
0 |
0 |
0 |
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| VIII. CERTIFICATION FOR OPTIONAL DATA |
| 1A. I certify to the best of my knowledge and belief that this report is correct and complete for Administration and Congressional oversight the program and for the purposes set forth in the award letter. |
| 2A. Typed or Printed Name and Title of Authorized Certifying Official: |
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Date Submitted: |
| 3A. Signature of Authorized Certifying Official: (click to sign) |
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Month Day Year |
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| APPRISE/05-21-14 DEA/OCS/ll/4-06-14 - Update |
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| OMB Control No. 0970-xxxx |
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