DOE F 540.3 U.S. DOE Weatherization Quarterly Program Report

DOE F 540.3 OMB Control No. 1910-5127

Expiration Date: 11/30/2016

U.S. Department of Energy

WEATHERIZATION ASSISTANCE PROGRAM

QUARTERLY PROGRAM REPORT

State: _______________ Budget period: / / - / / Grant Number:________________

I. GRANT OUTLAYS - FUNDS SUBJECT TO DOE PROGRAM RULES (rounded to the nearest dollar)

Reporting Period Quarter	/ - /	/ - /	/ - /	/ - /	Total To Date
	Q1	Q2	Q3	Q4
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 Federal Financial Report, line 10.e.

* Acquisition (actual cost to purchase) vehicle and equipment costs must be included on this form and are used to match net outlays on the FFR. Amortized vehicle and equipment costs are used to calculate the average cost per unit.

U.S. Department of Energy

WEATHERIZATION ASSISTANCE PROGRAM

QUARTERLY PROGRAM REPORT

State: _______________________ Budget period: / / - / / Grant Number:________________

II. GRANT PRODUCTION

Quarter	Q1	Q2	Q3	Q4	Total to Date
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
Renter-Occupied Single Family
Owner-Occupied 2-4 units per site
Renter Occupied 2-4 units per site
Multifamily, 5 or more units per site
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 Fuel
No Heating System
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.

III. COMMENTS

Submitted by_________________________________________________________________ Date_____________

Type name___________________________________________________________________

Title ___________________________________________________________________

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 Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

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 30 days after the end of the reporting period.

1. GRANT OUTLAYS - FUNDS SUBJECT TO DOE PROGRAM RULES

   1. 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.

   2. 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 FFR. Amortized vehicle and equipment costs are used to calculate the average cost per unit.

2. 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.

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

2. 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 the two Single-Family categories.

   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.

3. 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.

4. 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.

3. 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.