1 Household Report Short Form

OMB Clearance No.: 0970-0060 Expiration Date: XXXXXXXX LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-SHORT FORM
Grantee Name:						FFY:
Contact Person:						Phone:
Email Address:
The LIHEAP Household Report-Short Form is for use by all direct-grant Indian tribes/tribal organizations
a. You can find the full instructions for submitting this report - Click HERE
Required Data
Type of assistance		A. Number of assisted households
1. Heating
2. Heating (CARES Act funding only)
3. Heating (Reserved for other supplemental funding)
4. Cooling
5. Cooling (CARES Act funding only)
6. Cooling (Reserved for other supplemental funding)
7. Winter / year-round crisis
8. Winter / year-round crisis (CARES Act funding only)
9. Winter / year-round crisis (Reserved for other supplemental funding)
10. Summer crisis
11. Summer crisis (CARES Act funding only)
12. Summer crisis (Reserved for other supplemental funding)
13. Weatherization
14. Weatherization (CARES Act funding only)
15. Weatherization (Reserved for other supplemental funding)
Remarks
Please enter any explanation needed of the above-reported data:
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: