1 Household Report Short Form

OMB Clearance No.: 0970-0060 Expiration Date: XX/XX/2025 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-SHORT FORM
Recipient 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)
3. Heating (American Rescue Plan Act funding)
4. Heating (Reserved for other supplemental funding)
5. Cooling
6. Cooling (CARES Act funding)
7. Cooling (American Rescue Plan Act funding)
8. Cooling (Reserved for other supplemental funding)
9. Winter / year-round crisis
10. Winter / year-round crisis (CARES Act funding)
11. Winter / year-round crisis (American Rescue Plan Act funding)
12. Winter / year-round crisis (Reserved for other supplemental funding)
13. Summer crisis
14. Summer crisis (CARES Act funding)
15. Summer crisis (American Rescue Plan Act funding)
16. Summer crisis (Reserved for other supplemental funding)
17. Weatherization
18. Weatherization (CARES Act funding)
19. Weatherization (American Rescue Plan Act funding)
20. Weatherization (Reserved for other supplemental funding)
21. Other crisis assistance
22. Other crisis assistance (CARES Act funding)
23. Other crisis assistance (American Rescue Plan Act funding)
24. Other crisis assistance (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: