1 Household Report Long Form

Household Report - Long Form
OMB Clearance No.: 0970-0060
Expiration Date:

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM
LIHEAP HOUSEHOLD REPORT-LONG FORM

Grantee Information
Grantee Name:ARKANSAS

FFY2015

Contact Person:

Phone:

Email Address:

Instructions
The 50 States, District of Columbia, and the Commonwealth of Puerto Rico are required to
use the LIHEAP Household Report-Long Form in providing household counts for the designated
Federal Fiscal Year. The Report consists of the following six sections that are to include
unduplicated household counts for both LIHEAP assisted and LIHEAP applicant households.
I. Number of Assisted Households
II. Number of Assisted Households by Poverty Interval
III. Number of Assisted Households by Vulnerable Population
IV. Number of Applicant Households
V. Number of Applicant Households by Poverty Interval
VI. Number of Assisted Households by Young Child Age Category
Except for Section VI, the household counts for LIHEAP assisted and applicant households are
required under the LIHEAP statute. Section VI is optional. If LIHEAP funds are used for any other
type of service not listed in the sections below, describe the service and the total number of
households assisted with that service in the Notes Section.
The required data for LIHEAP assisted households for each State are included in the
Department's LIHEAP annual Report to Congress. The required data are also used in measuring
LIHEAP targeting 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.
Click HERE to read the expanded Household Report - Long Form Instructions.
Do the data below include estimated figures?
If YES, select the appropriate box in column A of Section I and Section IV for each type of assistance that has at least
one estimated data entry.

Select One
Yes
No

I. Number of Assisted Households
Number of assisted households
Type of LIHEAP assistance
1. Heating
2. Cooling

3.Crisis
a. Year Round
b. Winter

A. Select if
estimated data

B. Total Number of
Households

c. Summer
d. Emergency Furnace Repair & Replacement
e.
f.
4. Weatherization
5. Any type of LIHEAP assistance
6. Bill Payment Assistance
7. Nominal Payments

II. Number of Assisted Households by Poverty Interval
HHS Poverty Guidelines for Calendar Year 2013
Type of LIHEAP assistance

A. Under 75%
poverty

B. 75%-100%
poverty

C. 101%-125%
poverty

D. 126%-150%
poverty

E. Over 150%
poverty

1. Heating
2. Cooling

3.Crisis
a. Year Round
b. Winter
c. Summer
d. Emergency Furnace Repair & Replacement
e.
f.
4. Weatherization

III. Number of Assisted Households by Vulnerable Population
At least one households member who is a member of one the following target groups
Type of LIHEAP assistance

A. 60 years or older B. Disabled
(elderly)

C. Age 5 years or
under (young
child)

D. Elderly,
disabled, or young
child

A. Select if
estimated data

B. Total Number of
Households

1. Heating
2. Cooling

3.Crisis
a. Year Round
b. Winter
c. Summer
d. Emergency Furnace Repair & Replacement
e.
f.
4. Weatherization
5. Any type of LIHEAP assistance

IV. Number of Applicant Households
Number of applicant households
Type of LIHEAP assistance
1. Heating
2. Cooling

3.Crisis
a. Year Round

b. Winter
c. Summer
d. Emergency Furnace Repair & Replacement
e.
f.
4. Weatherization

V. Number of Applicant Households by Poverty Interval
HHS Poverty Guidelines for Calendar Year 2013
Type of LIHEAP assistance

A. Under 75%
poverty

B. 75%-100%
poverty

C. 101%-125%
poverty

D. 126%-150%
poverty

E. Over 150%
poverty

F. Income data
unavailable

1. Heating
2. Cooling

3.Crisis
a. Year Round
b. Winter
c. Summer
d. Emergency Furnace Repair
& Replacement
e.
f.
4. Weatherization

VI. Number of Assisted Households by Young Child Age Category (Optional)
At least one member who is
Type of LIHEAP assistance

A. Age 2 years or
under

B. Age 3 years
through 5 years

1. Heating
2. Cooling

3.Crisis
a. Year Round
b. Winter
c. Summer
d. Emergency Furnace Repair & Replacement
e.
f.
4. Weatherization
Notes

Certification
Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge.
I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalities. (U.S. Code, Title 18, Section 1001)
a. Name of Authorized Official:

d. Telephone:

b. Title of Authorized Official:

e. Email address:

c. Signature of Authorized Official:

f. Date Submitted: