Form 1 Annual LIHWAP Report

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Overview

Recipient Information
Use of Funds
Household Report
Performance Measures

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Sheet 1: Recipient Information

OMB Control No. 0970-0578

Expiration Date: 4/30/2022

Low Income Household Water Assistance Program Annual Report Form

Recipient Information

FY:

Recipient Name:

Contact Name:

Contact Phone:

Contact Email:

[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: Need to add hyperlink when available Click HERE to read the LIHWAP Annual Report Instructions.

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 penalties. (U.S. Code, Title 18, Section 1001)

a. Name of Authorized Official:

b. Title of Authorized Official:

c. Signature of Authorized Official:

d. Date Signed:

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Sheet 2: Use of Funds

Module 1: Use of Funds Report for Fiscal Year (FY)
Reporting Requirements: All LIHWAP grantees are required to complete the LIHWAP Use of Funds in providing estimates of sources and uses of funds, including obligated and expended funding of the given fiscal year (FY) for each type of LIHWAP assistance provided.
SECTION I. GRANT AWARD AMOUNTS
Enter the following amounts as submitted on the grantee's plan:
	A. Consolidated Appropriation Act, 2021 Funding	B. American Rescue Act, 2021 Funding	C. Reserve for Possible Future Funding
1. Actual Grant Award:
2. Estimated Household Benefit:
3. Estimated Outreach/Eligibility:
4. Estimated Administration - Recipient:
5. Estimated Administration - Subrecipient (if applicable):
6. Actual Admin Cost Cap (15%): Auto-Calculated	$0	$0	$0
SECTION II. USES OF LIHWAP HOUSEHOLD BENEFIT FUNDS
		FY (10/1 to 9/30)
		Amount Rounded to the Nearest Dollar
		Actual Funds Obligated	Actual Funds Expended
A. Type of LIHWAP Assistance Funds by Priority (Items 1-3)
1. Restoration of services funds
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0
(1) Specify--non-supplemental funds		$0	$0
(2) Specify--non-supplemental funds		$0	$0
(3) Specify--non-supplemental funds		$0	$0
2. Prevention of Disconnection funds
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0
(1) Specify--non-supplemental funds		$0	$0
(2) Specify--non-supplemental funds		$0	$0
(3) Specify--non-supplemental funds		$0	$0
3. Reduction of Rates Charged funds
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0
(1) Specify--non-supplemental funds		$0	$0
(2) Specify--non-supplemental funds		$0	$0
(3) Specify--non-supplemental funds		$0	$0
		FY (10/1 to 9/30)
		Amount Rounded to the Nearest Dollar
		Actual Funds Obligated	Actual Funds Expended
B. Type of LIHWAP Water and Wastewater Assistance Funds (Items 1-3)
1. Water and/or Wastewater
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0
(1) Specify--non-supplemental funds		$0	$0
(2) Specify--non-supplemental funds		$0	$0
(3) Specify--non-supplemental funds		$0	$0
2. Multiple Services that include water and other non-water services
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0
(1) Specify--non-supplemental funds		$0	$0
(2) Specify--non-supplemental funds		$0	$0
(3) Specify--non-supplemental funds		$0	$0
3. Other Water Services*
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0
(1) Specify--non-supplemental funds		$0	$0
(2) Specify--non-supplemental funds		$0	$0
(3) Specify--non-supplemental funds		$0	$0
*Below please specify Other Water Services funded by LIHWAP
Response:
SECTION III. USES OF LIHWAP OUTREACH/ELIGIBILITY DETERMINATION AND ADMINISTRATION FUNDS
		FY (10/1 to 9/30)
		Amount Rounded to the Nearest Dollar
		Estimated Funding Allocations	Funding Obligated	Funding Expended
1. Outreach/Eligibility
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0	$0
(1) Specify--non-supplemental funds		$0	$0	$0
(2) Specify--non-supplemental funds		$0	$0	$0
(3) Specify--non-supplemental funds		$0	$0	$0
2. Administration - Recipient
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0	$0
(1) Specify--non-supplemental funds		$0	$0	$0
(2) Specify--non-supplemental funds		$0	$0	$0
(3) Specify--non-supplemental funds		$0	$0	$0
3. Administration - Subrecipients (if applicable)
a. Specify Consolidated Appropriation Act, 2021 funds		$0	$0	$0
b. Specify American Rescue Act, 2021 funds		$0	$0	$0
c. Other --Non-supplemental funds RESERVED FOR POSSIBLE FUTURE FUNDING		$0	$0	$0
(1) Specify--non-supplemental funds		$0	$0	$0
(2) Specify--non-supplemental funds		$0	$0	$0
(3) Specify--non-supplemental funds		$0	$0	$0
Remarks:

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Sheet 3: Household Report

Module 2: Household Report for Fiscal Year (FY)
I. Number of Households		A. Total Number of Households
1. Total Unduplicated Household Applicants
2. Total Unduplicated Households Assisted
3. Total Waitlisted Households for Non-availability of Funds
II. Number of Assisted Households by Assistance Type
Type of LIHWAP assistance		A. Total Number of Households
1. Restoration of services
2. Prevention of disconnections of services
3. Reduction of current rates charged
III. Number of Assisted Households by Poverty Interval
		HHS Poverty Guidelines for Most Recent
Type of LIHWAP assistance		A. Under 75% poverty	B. 75%-100% poverty	C. 101%-125% poverty	D. 126%-150% poverty	E. Over 150% poverty
1. Restoration of services
2. Prevention of disconnections of services
3. Reduction of current rates charged
IV. Number of Assisted Households by Vulnerable Population
			At least one household member is a member of one of the following target groups:
Type of LIHWAP assistance			A. 60 years or older (elderly)	B. Disabled	C. Age 5 years or under (young child)	D. Any (elderly, disabled, or young child)
1. Restoration of services
2. Prevention of disconnections of services
3. Reduction of current rates charged
4. Any type of LIHWAP assistance
V. Number of Assisted Household Applicants by Race and Ethnicity
A. Ethnicity	Number of Household Applicants
1. Hispanic, Latino, or Spanish Origins
2. Not Hispanic, Latino, or Spanish Origins
3. Unknown/not reported
4. TOTAL (Auto Calculated)	0
B. Race	Number of Household Applicants
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
6. Multi-race (two or more of the above)
7. Other
8. Unknown/not reported
9. TOTAL (Auto Calculated)	0
VI. Number of Assisted Household Applicants by Gender	Number of Household Applicants
1. Self Identified Male
2. Self Identified Female
3. Other
4. Unknown/not reported
5. TOTAL (Auto Calculated)	0
VII. Housing Type	Number of Assisted Households
1. Own
2. Rent with separately billed utilities
3. Rent with utilities included in fee
4. Other
5. Unknown/not reported
6. TOTAL (Auto Calculated)	0
VIII. Assisted Household Members by Race and Ethnicity*
A. Ethnicity	Number of Household Members
1. Hispanic, Latino, or Spanish Origins
2. Not Hispanic, Latino, or Spanish Origins
3. Unknown/not reported
4. TOTAL (Auto Calculated)	0
*See Instructions
B. Race*	Number of Household Members
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
6. Multi-race (two or more of the above)
7. Other
8. Unknown/not reported
9. TOTAL (Auto Calculated)	0
*See Instructions
IX. Assisted Household Members by Gender*	Number of Household Members
1. Self Identified Male
2. Self Identified Female
3. Other
4. Unknown/not reported
5. TOTAL (Auto Calculated)	0
*See Instructions
X. Use of Funds to Non-Public Water Systems for Emergency Home Water Service
*This question is only applicable to recipients that were approved to use 'Non-Public Water Systems for Emergency Home Water Service' funds in their LIHWAP plan
Type of Emergency Home Water Service	Number of Households
1. Private Water Delivery as Supplemental Drinking Water Service
2. Private Waste Hauling as Supplemental Wastewater Service
3. Other Supplemental Water Services*
*Below please specify Other Water Services funded by LIHWAP
Response:
Remarks
Enter any explanation needed regarding the reliability and/or validity of the above-reported data:
Response:

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Sheet 4: Performance Measures

Module 3: Performance Data Report for Fiscal Year (FY)
I. WATER BURDEN TARGETING
	Service Type
All Households (Based on billing period covered by assistance (i.e., monthly, quarterly))	Restoration of Service	Prevention of Disconnection	Reduction of Current Rates Charged
1. Average Water Benefit Payment
2. Pre Water Burden Average
3. Post Water Burden Average	If Applicable	If Applicable
II. RESTORATION OF HOME Water/Wastewater SERVICE
		Service Type
Number of All LIHWAP-Assisted Households that Had:	All Households	Water or Wastewater	Multiple Services	Other Water Services
1. Restoration of Home Water/Wastewater Service (Unduplicated Count)	Auto-Calculated	0	0	0
2. Restoration of Home Water/Wastewater Service (Duplicated Count)	Auto-Calculated	If Applicable	If Applicable	If Applicable
III. PREVENTION OF LOSS OF HOME Water/Wastewater SERVICE
		Service Type
Number of All LIHWAP-Assisted Households that Had:	All Households	Water or Wastewater	Multiple Services	Other Water Services
1. Prevention of Loss of Home Water/Wastewater Service (Unduplicated Count)	Auto-Calculated	0	0	0
2. Prevention of Loss of Home Water/Wastewater Service (Duplicated Count)	Auto-Calculated	If Applicable	If Applicable	If Applicable
IV. RATE REDUCTION OF CURRENT HOME Water/Wastewater SERVICE
		Service Type
Number of All LIHWAP-Assisted Households that Had:	All Households	Water or Wastewater	Multiple Services	Other Water Services
1. Rate Reduction of Current Home Water/Wastewater Service (Unduplicated Count)	Auto-Calculated	0	0	0
2. Rate Reduction of Current Home Water/Wastewater Service (Duplicated Count)	Auto-Calculated	If Applicable	If Applicable	If Applicable