Form 1 LIHEAP Perforrmance Data

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Overview

Module 1 (Grantee Survey)
Module 2A - All Households
Module 2B - CARES Subset
Module 2C - ARPA Subset
Module 3 (Optional Measures)

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Sheet 1: Module 1 (Grantee Survey)

OMB Control No. 0970-0449 LIHEAP Performance Data Form for Federal Fiscal Year (FFY) 2021 Expiration Date: XX/XX/XX
MODULE 1 (LIHEAP Grantee Survey)
SECTION I. GRANTEE INFORMATION
Grantee Name:	Date:	Contact Person:			Phone Number:
SECTION II. REPORTING REQUIREMENTS
The 50 States and the District of Columbia are required to complete the LIHEAP Grantee Survey Section of the LIHEAP Performance Data Form 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 10/1/16 for each type of LIHEAP assistance provided in FFY 2021. Additionally, the 50 states and the District of Columbia are required to complete the LIHEAP Performance Measurement Section of the LIHEAP Performance Data Form. This Federal Report provides data on three required LIHEAP Performance Measures for Federal Fiscal Year (FFY) 2021, the period of October 1, 2020 - September 30, 2021. 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.
SECTION III. ESTIMATED SOURCES OF LIHEAP FUNDS
	ALL OF FFY 2021 10/1/2020 TO 9/30/2021)
	Amount Rounded to the Nearest Dollar
A. All Funds Except CARES Act and other Supplemental Funding (Items 1-9)
1. FFY LIHEAP Block Grant Allotment (Net of Indian Tribal Set-Asides)--regular funds		This value is pre-populated and locked from editing. Please review and confirm that it is correct. $0
2. FFY Emergency Contingency Funds (Net of Indian Tribal Set-Asides)		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
3. LIHEAP Block Grant Funds from Previous FFY Reallotted to FFY		This value is pre-populated and locked from editing. Please review and confirm that it is correct. $0
4. Previous FFY Unobligated Emergency Contingency Funds, not Subject to 10% Carryover Limit		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
5. All Funds Carried Over From Previous FFY (except Funds in item 4 and 9 in this Section)		This value is pre-populated using the amount reported in your prior Module 1 Grantee Survey. This line is editable and should be updated as needed. $0
6. Petroleum Violation Escrow (Oil Overcharge) Funds Obligated in FFY		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
7. FFY Residential Energy Assistance Challenge (REACH) Program		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
8. Previous FFY REACH Program award obligated in FFY		Pre-populated & locked. Added by Peter E. in response to Lauren's request from last year $0
9. FFY Leveraging Incentive Award		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
10. Previous FFY Leveraging Incentive Award obligated in FFY		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
B. Estimated Subtotal Sources of Funds--Non-CARES/Supplemental Funding
11. Sum of Items 1-10. This should equal the sum in Section IV. Column D, Item 13.		This value is auto-calculated by summing items 1-10 of this section. Grantees are locked from editing this field. $0
C. All Supplemental Funds (Items 12-14)
[Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: For FY 2020, this field was the allotment. For FY 2021, it should be the amount a grantee carried over to FY 2021. 12. Previous unobligated CARES Act Allotment, not Subject to 10% Carryover Limit. This should equal the sum in Section IV Column D, Item 23.		This value is pre-populated, but open for editing. $0
[Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: This is where ARP goes. For FY 2021, it is fine as is. Fir FY 2021, it should be the amount a grantee carried over. 13. American Rescue Plan Act Allotment (Net of Indian Tribal Set-Asides). This should equal the sum in Section IV Column D, Item 33.		This value is pre-populated and locked from editing. $0
14. [RESERVED, if applicable] Other Supplemental2 Allotment (Net of Indian Tribal Set-Asides). This should equal the sum in Section IV. Column D, Item 43.		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
D. Estimated Subtotal Sources of Supplemental Funds
15. Sum of Items 12-14. This should equal the sum in Section IV. Column D, Item 44.		This value is auto-calculated by summing items 12-14 of this section. Grantees are locked from editing this field. $0
E. Estimated Total of Sources of All Funds
16. Item 11 plus Item 15. This should equal the sum in Section IV. Column D, Item 45.		This value is auto-calculated by summing items 11 & 15 of this section. Grantees are locked from editing this field. $0
SECTION IV. ESTIMATED USES OF LIHEAP FUNDS
A. Type of LIHEAP Assistance--Non-Supplemental Funds (Items 1-4)		All of FFY 2021 (10/1/2020) to 9/30/2021)
		Amount Rounded to the Nearest Dollar
		Total Funds/Awards		Average Household Benefit	Maximum Annual Dollar Income for 4-Person Household as of the effective date
1. Heating Assistance Benefits--non-supplemental funds		$0		$0	$0
2. Cooling Assistance Benefits--non-supplemental funds		$0		$0	$0
3. Crisis Benefits by Type--non-supplemental funds
a. Winter Crisis Benefits--non-supplemental funds		$0		$0	$0
b. Summer Crisis Benefits--non-supplemental funds		$0		$0	$0
c. Year-round Crisis Benefits--non-supplemental funds		$0		$0	$0
d. Other Crisis Benefits--non-supplemental funds		This value is auto-calculated by summing sums sub-sub-items 3.d.(1) - 3.d.(3) below. Grantees are locked from editing this field. $0
(1) Specify--non-supplemental funds		$0		$0
(2) Specify--non-supplemental funds		$0		$0	$0
(3) Specify--non-supplemental funds		$0		$0	$0
4. Weatherization Assistance Benefits--non-supplemental funds		$0			$0
B. Other Permitted Uses of LIHEAP Funds--non-supplemental funds (Items 5-12)
5. Nominal Payments--non-supplemental funds		$0
6. FFY Unobligated Funds (excluding funds in Items 8 & 9) Carried Over to next FFY--non-supplemental funds		$0
7. FFY Allowable Unobligated Emergency Contingency Funds, not Subject to 10% Carryover Limit, Obligated in next FFY		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
8. FFY Leveraging Incentive Award Obligated in next FFY		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
9. FFY LIHEAP Block Grant Allotment Used to Identify, Develop & Demonstrate Leveraging Incentive Activities--non-supplemental funds		$0
10. Assurance 16 Activities--non-supplemental funds		$0
11. FFY Residential Energy Assistance Challenge (REACH) Program		This value is pre-populated with $0 and locked from editing because this source of funds is not applicable for this report. $0
12. Administration/Planning Costs--non-supplemental funds		$0
C. Estimated Total Uses of Funds--non-supplemental funds
13. Sum of Items 1-4 and 5-12. This should equal the sum in Section III. Column D, Item 11.		This value is auto-calculated by summing items 1, 2, 4, 6, 7, 8, 9, 10, 11, 12, and 13; and sub-items 3.a. -3.d; of this section. Grantees are locked from editing this field. $0
Q1. Obligated funding for a given type of assistance in current FFY, but will serve households in the subsequent FFY--regular funds		-Select-
Q2. Average Household Benefits are estimated due to unique program operation, rather than directly calculated--regular funds		-Select-
D. Type of LIHEAP Assistance--CARES Act Funds (Items 14-17)		All of FFY 2021 (10/1/2020) to 9/30/2021)
		Amount Rounded to the Nearest Dollar
		Total Funds/Awards		Average Household Benefit	Maximum Annual Dollar Income for 4-Person Household as of the effective date
14. Heating Assistance Benefits--CARES Act Funds		$0		$0	$0
15. Cooling Assistance Benefits--CARES Act Funds		$0		$0	$0
16. Crisis Benefits by Type--CARES Act Funds
a. Winter Crisis Benefits--CARES Act Funds		$0		$0	$0
b. Summer Crisis Benefits--CARES Act Funds		$0		$0	$0
c. Year-round Crisis Benefits--CARES Act Funds		$0		$0	$0
d. Other Crisis Benefits--CARES Act Funds		This value is auto-calculated by summing sums sub-sub-items 17.d.(1) - 17.d.(3) below. Grantees are locked from editing this field. $0
(1) Specify--CARES Act Funds		$0		$0	$0
(2) Specify--CARES Act Funds		$0		$0	$0
(3) Specify--CARES Act Funds		$0		$0	$0
17. Weatherization Assistance Benefits--CARES Act Funds		$0			$0
E. Other Permitted Uses of LIHEAP Funds--CARES Act Funds (Items 18-22)
18. Nominal Payments--CARES Act Funds		$0
19. Unobligated CARES Act Funds Carried Over to next FFY		$0
20. FFY LIHEAP Block Grant Allotment Used to Identify, Develop & Demonstrate Leveraging Incentive Activities--CARES Act Funds		$0
21. Assurance 16 Activities--CARES Act Funds		$0
22. Administration/Planning Costs--CARES Act Funds		$0
F. Estimated Total Uses of Funds--CARES Act Funds
23. Sum of Items 14-17 and 18-22. This should equal the sum in Section III. Column D, Item 12.		This value is auto-calculated by summing items 15, 16, 18, 20, 21, 22, 23, 24; and sub-items 17.a. -17.d; of this section. Grantees are locked from editing this field. $0
Q3. Obligated funding for a given type of assistance in current FFY, but will serve households in the subsequent FFY--CARES Act Funds		-Select-
Q4 Average Household Benefits are estimated due to unique program operation, rather than directly calculated--CARES Act Funds		-Select-
G. Type of LIHEAP Assistance--ARPA Funds: (Items 24-27)		All of FFY 2021 (10/1/2020) to 9/30/2021)
		Amount Rounded to the Nearest Dollar
		Total Funds/Awards		Average Household Benefit	Maximum Annual Dollar Income for 4-Person Household as of the effective date
24. Heating Assistance Benefits--ARPA Funds		$0		$0	$0
25. Cooling Assistance Benefits--ARPA Funds		$0		$0	$0
26. Crisis Benefits by Type--ARPA Funds
a. Winter Crisis Benefits--ARPA Funds		$0		$0	$0
b. Summer Crisis Benefits--ARPA Funds		$0		$0	$0
c. Year-round Crisis Benefits--ARPA Funds		$0		$0	$0
d. Other Crisis Benefits--ARPA Funds		Locked with formula that sums sub-sub-items 28.d.(1) - 28.d.(3) $0
(1) Specify--ARPA Funds		$0		$0	$0
(2) Specify--ARPA Funds		$0		$0	$0
(3) Specify--ARPA Funds		$0		$0	$0
27. Weatherization Assistance Benefits--ARPA Funds		$0			$0
H. Other Permitted Uses of LIHEAP Funds--ARPA Funds (Items 28-32)
28. Nominal Payments--ARPA Funds		$0
29. Unobligated ARPA Funds Funds Carried Over to next FFY		$0
30. FFY LIHEAP Block Grant Allotment Used to Identify, Develop & Demonstrate Leveraging Incentive Activities--ARPA Funds		$0
31. Assurance 16 Activities--ARPA Funds		$0
32. Administration/Planning Costs--ARPA Funds		$0
I. Estimated Total Uses of Funds--ARPA Funds
33. Sum of Items 24-27 and 28-32. This should equal the sum in Section III. Column D, Item 13.		Locked with formula that sums Items 26, 27, 29, 31, 32, 33, 34, and 35; and sub-items 28.a. -28.d; of this section $0
Q5. Obligated funding for a given type of assistance in current FFY, but will serve households in the subsequent FFY--ARPA Funds		Select "Yes" or "No" from the dropdown list.
Q6. Average Household Benefits are estimated due to unique program operation, rather than directly calculated--ARPA Funds		Select "Yes" or "No" from the dropdown list.
J. [RESERVED, if applicable] Other Supplemental Funds2: (Items 34-37)		All of FFY 2021 (10/1/2020) to 9/30/2021)
		Amount Rounded to the Nearest Dollar
		Total Funds/Awards		Average Household Benefit	Maximum Annual Dollar Income for 4-Person Household as of the effective date
34. Heating Assistance Benefits--Other Supplemental2 [reserved]		$0		$0	$0
35. Cooling Assistance Benefits--Other Supplemental2		$0		$0	$0
36. Crisis Benefits by Type--Other Supplemental2
a. Winter Crisis Benefits--Other Supplemental2		$0		$0	$0
b. Summer Crisis Benefits--Other Supplemental2		$0		$0	$0
c. Year-round Crisis Benefits--Other Supplemental2		$0		$0	$0
d. Other Crisis Benefits--Other Supplemental2		Locked with formula that sums sub-sub-items 39.d.(1) - 39.d.(3) $0
(1) Specify--Other Supplemental2		$0		$0	$0
(2) Specify--Other Supplemental2		$0		$0	$0
(3) Specify--Other Supplemental2		$0		$0	$0
37. Weatherization Assistance Benefits--Other Supplemental2		$0			$0
K. Other Permitted Uses of LIHEAP Funds--Other Supplemental2 (Items 38-42)
38. Nominal Payments--Other Supplemental2		$0
39. Unobligated Other Supplemental2 Funds Carried Over to next FFY		Pre-populated $0
40. FFY LIHEAP Block Grant Allotment Used to Identify, Develop & Demonstrate Leveraging Incentive Activities--Other Supplemental2		$0
41. Assurance 16 Activities--Other Supplemental2		$0
42. Administration/Planning Costs--Other Supplemental2		$0
L. Estimated Total Uses of Funds--Other Supplemental2
43. Sum of Items 34-37 and 38-42. This should equal the sum in Section III. Column D, Item 14.		Locked with formula that sums Items 37, 38, 40, 42, 43, 44, 45, and 46; and sub-items 39.a. -39.d; of this section $0
Q7. Obligated funding for a given type of assistance in current FFY, but will serve households in the subsequent FFY--Other Supplemental2		Select "Yes" or "No" from the dropdown list.
Q8. Average Household Benefits are estimated due to unique program operation, rather than directly calculated--Other Supplemental2		Select "Yes" or "No" from the dropdown list.
Notes: Include any notes. Please indicate type of LIHEAP assistance and item being referenced.
M. Estimated Subtotal Uses of Supplemental Funds
44. Sum of Items 23, 33, and 43. This should equal the sum in Section III. Column D, Item 15.		This value is auto calculated by summing Items 25, 36, and 47 of this section. Grantees are locked from editing this field. $0
N. Estimated Subtotal Uses of All Funds
45. Sum of Items 13 and 44. This should equal the sum in Section III. Column D, Item 16.		This value is auto calculated by summing Items 14 and 48 of this section. Grantees are locked from editing this field. $0
-Select-
Yes
No

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Sheet 2: Module 2A - All Households

OMB Control No. 0970-0449 LIHEAP Performance Data Form for Federal Fiscal Year (FFY) 2021 Expiration Date: XX/XX/XX
Module 2A (Required LIHEAP Performance Measures)
V. ENERGY BURDEN TARGETING
		Bill Payment-Assisted Household Main Fuel
	All Households	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
A. Unduplicated Number of LIHEAP Bill Payment-Assisted Households	Auto-Calculated	0	0	0	0	0
B. Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)	Auto-Calculated	0	0	0	0	0
2. Average Annual Household Income	Auto-Calculated	$0	$0	$0	$0	$0
3. Average Annual Total LIHEAP Benefit per Household (including Heating, Cooling, Crisis, Supplemental Benefits)	Auto-Calculated	$0	$0	$0	$0	$0
4. Average Annual Main Heating Fuel Bill	Auto-Calculated	$0	$0	$0	$0	$0
5. Average Annual Electricity Bill	Auto-Calculated	This value is pre-populated with $0 because the average bill amount for electricity for Electric Main Heat households is reported in Line 4 above.” $0	$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
C. High Burden Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of High Burden Households (Top 25%) with 12 Consecutive Months of Bill Data (Main Fuel and Electric)	Auto-Calculated	0	0	0	0	0
2. Average Annual Household Income for High Burden Households	Auto-Calculated	$0	$0	$0	$0	$0
3. Average Annual Total LIHEAP Benefit per High Burden Household (including Heating, Cooling, Crisis, Supplemental Benefits)	Auto-Calculated	$0	$0	$0	$0	$0
4. Average Annual Main Heating Fuel Bill for High Burden Households	Auto-Calculated	$0	$0	$0	$0	$0
5. Average Annual Electricity Bill for High Burden Households	Auto-Calculated	This value is pre-populated with $0 because the average bill amount for electricity for Electric Main Heat households is reported in Line 4 above.” $0	$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
D. Benefit Targeting Index for High Burden Households:	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated
E. Burden Reduction Targeting Index for High Burden Households:	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated
VI. RESTORATION OF HOME ENERGY SERVICE
		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
2. Fuel Delivered to Home that Ran Out of Fuel	Auto-Calculated			0	0	0
3. Repair/Replacement of Inoperable Home Energy Equipment	Auto-Calculated	0	0	0	0	0
VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE
		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
2. Imminent Risk of Running out of Fuel	Auto-Calculated			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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Sheet 3: Module 2B - CARES Subset

OMB Control No. 0970-0449 LIHEAP Performance Data Form for Federal Fiscal Year (FFY) 2021 Expiration Date: XX/XX/XX
Module 2B (Required LIHEAP Performance Measures)
V. ENERGY BURDEN TARGETING
		Bill Payment-Assisted Household Main Fuel
	All Households	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
A. Unduplicated Number of Household that Received Supplemental CARES Assistance, Alone or in Combination with Other Sources of Funding	Auto-Calculated	0	0	0	0	0
B. Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)	Auto-Calculated	0	0	0	0	0
2. Average Annual Household Income	Auto-Calculated	$0	$0	$0	$0	$0
3. Average Annual Total CARES Benefit per Household (excluding benefit from regular funds or ARP)	Auto-Calculated	$0	$0	$0	$0	$0
4. Average Annual Main Heating Fuel Bill	Auto-Calculated	$0	$0	$0	$0	$0
5. Average Annual Electricity Bill	Auto-Calculated	This value is pre-populated with $0 because the average bill amount for electricity for Electric Main Heat households is reported in Line 4 above.” $0	$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
C. High Burden Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of High Burden Households (Top 25%) with 12 Consecutive Months of Bill Data (Main Fuel and Electric)	Auto-Calculated	0	0	0	0	0
2. Average Annual Household Income for High Burden Households	Auto-Calculated	$0	$0	$0	$0	$0
3. Average Annual Total CARES Benefit per High Burden Household (excluding benefit from regular funds or ARP)	Auto-Calculated	$0	$0	$0	$0	$0
4. Average Annual Main Heating Fuel Bill for High Burden Households	Auto-Calculated	$0	$0	$0	$0	$0
5. Average Annual Electricity Bill for High Burden Households	Auto-Calculated	This value is pre-populated with $0 because the average bill amount for electricity for Electric Main Heat households is reported in Line 4 above.” $0	$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
D. Benefit Targeting Index for High Burden Households:	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated
E. Burden Reduction Targeting Index for High Burden Households:	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated
VI. RESTORATION OF HOME ENERGY SERVICE
		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 because of CARES funds, alone or in combination with other sources	Auto-Calculated	0	0
2. Fuel Delivered to Home that Ran Out of Fuel because of CARES funds, alone or in combination with other sources	Auto-Calculated			0	0	0
3. Repair/Replacement of Inoperable Home Energy Equipment using CARES, alone or in combination with other sources	Auto-Calculated	0	0	0	0	0
VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE
		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 & CARES Assistance, alone or in combination with other sources	Auto-Calculated	0	0
2. Imminent Risk of Running out of Fuel & CARES LIHEAP Assistance Prevented Loss, alone or in combination with other sources	Auto-Calculated			0	0	0
3. Repair/Replacement of Operable Equipment using CARES, alone or in combination with other sources, to Prevent Imminent Home Energy Loss	Auto-Calculated	0	0	0	0	0

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Sheet 4: Module 2C - ARPA Subset

OMB Control No. 0970-0449 LIHEAP Performance Data Form for Federal Fiscal Year (FFY) 2021 Expiration Date: XX/XX/XX
Module 2C (Required LIHEAP Performance Measures)
V. ENERGY BURDEN TARGETING
		Bill Payment-Assisted Household Main Fuel
	All Households	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
A. Unduplicated Number of Household that Received Supplemental ARPA Assistance, Alone or in Combination with Other Sources of Funding	Auto-Calculated	0	0	0	0	0
B. Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)	Auto-Calculated	0	0	0	0	0
2. Average Annual Household Income	Auto-Calculated	$0	$0	$0	$0	$0
3. Average Annual Total ARPA Benefit per Household (excluding benefit from regular funds or CARES)	Auto-Calculated	$0	$0	$0	$0	$0
4. Average Annual Main Heating Fuel Bill	Auto-Calculated	$0	$0	$0	$0	$0
5. Average Annual Electricity Bill	Auto-Calculated	This value is pre-populated with $0 because the average bill amount for electricity for Electric Main Heat households is reported in Line 4 above.” $0	$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
C. High Burden Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of High Burden Households (Top 25%) with 12 Consecutive Months of Bill Data (Main Fuel and Electric)	Auto-Calculated	0	0	0	0	0
2. Average Annual Household Income for High Burden Households	Auto-Calculated	$0	$0	$0	$0	$0
3. Average Annual Total ARPA Benefit per High Burden Household (excluding benefit from regular funds or CARES)	Auto-Calculated	$0	$0	$0	$0	$0
4. Average Annual Main Heating Fuel Bill for High Burden Households	Auto-Calculated	$0	$0	$0	$0	$0
5. Average Annual Electricity Bill for High Burden Households	Auto-Calculated	This value is pre-populated with $0 because the average bill amount for electricity for Electric Main Heat households is reported in Line 4 above.” $0	$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
D. Benefit Targeting Index for High Burden Households:	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated
E. Burden Reduction Targeting Index for High Burden Households:	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated
VI. RESTORATION OF HOME ENERGY SERVICE
		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 because of ARPA funds, alone or in combination with other sources	Auto-Calculated	0	0
2. Fuel Delivered to Home that Ran Out of Fuel because of ARPA funds, alone or in combination with other sources	Auto-Calculated			0	0	0
3. Repair/Replacement of Inoperable Home Energy Equipment using ARPA, alone or in combination with other sources	Auto-Calculated	0	0	0	0	0
VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE
		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 & ARPA Assistance, alone or in combination with other sources	Auto-Calculated	0	0
2. Imminent Risk of Running out of Fuel & ARPA LIHEAP Assistance Prevented Loss, alone or in combination with other sources	Auto-Calculated			0	0	0
3. Repair/Replacement of Operable Equipment using ARPA, alone or in combination with other sources, to Prevent Imminent Home Energy Loss	Auto-Calculated	0	0	0	0	0

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Sheet 5: Module 3 (Optional Measures)

OMB Control No. 0970-0449 LIHEAP Performance Data Form for Federal Fiscal Year (FFY) 2021 Expiration Date: XX/XX/XX
LIHEAP Performance Measures
Module 3. (Optional LIHEAP Performance Measures)
V. ENERGY BURDEN TARGETING (OPTIONAL MEASURES)
		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	Auto-Calculated	0	0	0	0	0
2. Average Annual Main Heating Usage	Auto-Calculated	0	0	0	0
B. High Burden Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Average Annual Electricity Usage for High Burden	Auto-Calculated	0	0	0	0	0
2. Main Heating Usage for High Burden	Auto-Calculated	0	0	0	0
C. Unduplicated Number of LIHEAP Bill Payment-Assisted Households that Use:
1. Electricity as Supplemental Heating Fuel	Auto-Calculated		0	0	0	0
2. Wood as Supplemental Heating Fuel	Auto-Calculated	0	0	0	0	0
3. Other Supplemental Heating Fuel	Auto-Calculated	0	0	0	0	0
4. Central Air Conditioning	Auto-Calculated	0	0	0	0	0
5. Window/Wall A/C (including evaporative cooler)	Auto-Calculated	0	0	0	0	0
VI. RESTORATION OF HOME ENERGY SERVICE (OPTIONAL MEASURES)
		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	Auto-Calculated	0	0	0	0	0
VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE (OPTIONAL MEASURES)
		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	Auto-Calculated	0	0	0	0	0
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:					Date Submitted:
3A. Signature of Authorized Certifying Official: (click to sign)					Month Day Year