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:						FFY:
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						A. Select if estimated data	B. Total Number of 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.Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (Reserved for other supplemental funding)
d. Winter
e. Winter (CARES Act funding only)
f. Winter (Reserved for other supplemental funding)
g. Summer
b. Summer (CARES Act funding only)
c. Summer (Reserved for other supplemental funding)
g. Emergency Furnace Repair & Replacement
b. Emergency Furnace Repair & Replacement (CARES Act funding only)
c. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
8. Weatherization
9. Weatherization (CARES Act funding only)
10. Weatherization (Reserved for other supplemental funding)
11. Any type of LIHEAP assistance
12. Any type of LIHEAP assistance (CARES Act funding only)
13. Any type of LIHEAP assistance (Reserved for other supplemental funding)
14. Bill Payment Assistance
15. Bill Payment Assistance (CARES Act funding only)
16. Bill Payment Assistance (Reserved for other supplemental funding)
17. Nominal Payments
18. Nominal Payments (CARES Act funding only)
19. Nominal Payments (Reserved for other supplemental funding)
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. 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.Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (Reserved for other supplemental funding)
d. Winter
e. Winter (CARES Act funding only)
f. Winter (Reserved for other supplemental funding)
g. Summer
h. Summer (CARES Act funding only)
i. Summer (Reserved for other supplemental funding)
j. Emergency Furnace Repair & Replacement
k. Emergency Furnace Repair & Replacement (CARES Act funding only)
l. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
8. Weatherization
9. Weatherization (CARES Act funding only)
10. Weatherization (Reserved for other supplemental funding)
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 (elderly)	B. Disabled	C. Age 5 years or under (young child)	D. Elderly, disabled, or young child
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.Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (Reserved for other supplemental funding)
d. Winter
e. Winter (CARES Act funding only)
f. Winter (Reserved for other supplemental funding)
g. Summer
h. Summer (CARES Act funding only)
i. Summer (Reserved for other supplemental funding)
j. Emergency Furnace Repair & Replacement
k. Emergency Furnace Repair & Replacement (CARES Act funding only)
l. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
8. Weatherization
9. Weatherization (CARES Act funding only)
10. Weatherization (Reserved for other supplemental funding)
11. Any type of LIHEAP assistance
12. Any type of LIHEAP assistance (CARES Act funding only)
13. Any type of LIHEAP assistance (Reserved for other supplemental funding)
IV. Number of Applicant Households
Number of applicant households
Type of LIHEAP assistance						A. Select if estimated data	B. Total Number of 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.Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (Reserved for other supplemental funding)
d. Winter
e. Winter (CARES Act funding only)
f. Winter (Reserved for other supplemental funding)
g. Summer
h. Summer (CARES Act funding only)
i. Summer (Reserved for other supplemental funding)
j. Emergency Furnace Repair & Replacement
k. Emergency Furnace Repair & Replacement (CARES Act funding only)
l. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
8. Weatherization
9. Weatherization (CARES Act funding only)
10. Weatherization (Reserved for other supplemental funding)
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. 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.Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (Reserved for other supplemental funding)
d. Winter
e. Winter (CARES Act funding only)
f. Winter (Reserved for other supplemental funding)
g. Summer
h. Summer (CARES Act funding only)
i. Summer (Reserved for other supplemental funding)
j. Emergency Furnace Repair & Replacement
k. Emergency Furnace Repair & Replacement (CARES Act funding only)
l. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
8. Weatherization
9. Weatherization (CARES Act funding only)
10. Weatherization (Reserved for other supplemental funding)
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. 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.Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (Reserved for other supplemental funding)
d. Winter
e. Winter (CARES Act funding only)
f. Winter (Reserved for other supplemental funding)
g. Summer
h. Summer (CARES Act funding only)
i. Summer (Reserved for other supplemental funding)
j. Emergency Furnace Repair & Replacement
k. Emergency Furnace Repair & Replacement (CARES Act funding only)
l. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
8. Weatherization
9. Weatherization (CARES Act funding only)
10. Weatherization (Reserved for other supplemental funding)
Remarks
Enter any explanation needed regarding the reliability and/or validity 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:
b. Title of Authorized Official:
c. Signature of Authorized Official: