1 Household Report Long Form

Household Report - Long Form
OMB Clearance No.: 0970-0060 Expiration Date: XX/XX/2025 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-LONG FORM
Recipient Information
Recipient Name:						FFY:
Contact Person:						Phone:
Email Address:
Instructions
The 50 States, District of Columbia, 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 Assisted Households by Young Child Age Category V: Optional Number of Assisted Households Owner/Renter Status VI: Number of Assisted Household Applicants by Race and Ethnicity VII: Number of Assisted Household Applicants by Gender VIII: Optional Measure: Number of Assisted Household Members by Race and Ethnicity IX: Optional Measure: Number of Assisted Household Members by Gender 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)
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. Crisis
a. Year Round
b. Year Round (CARES Act funding)
c. Year Round (American Rescue Plan Act funding)
d. Year Round (Reserved for other supplemental funding)
e. Winter
f. Winter (CARES Act funding)
g. Winter (American Rescue Plan Act funding)
h. Winter (Reserved for other supplemental funding)
i. Summer
j. Summer (CARES Act funding)
k. Summer (American Rescue Plan Act funding)
l. Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair & Replacement
n. Emergency Furnace Repair & Replacement (CARES Act funding)
o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)
p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
q. Other Crisis Assistance
r. Other Crisis Assistance (CARES Act funding)
s. Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance (Reserved for other supplemental funding)
10. Weatherization
11. Weatherization (CARES Act funding)
12. Weatherization (American Rescue Plan Act funding)
13. Weatherization (Reserved for other supplemental funding)
14. Any type of LIHEAP assistance
15. Any type of LIHEAP assistance (CARES Act funding)
16. Any type of LIHEAP assistance (American Rescue Plan Act funding)
17. Any type of LIHEAP assistance (Reserved for other supplemental funding)
18. Bill Payment Assistance
19. Bill Payment Assistance (CARES Act funding)
20. Bill Payment Assistance (American Rescue Plan Act funding)
21. Bill Payment Assistance (Reserved for other supplemental funding)
22. Nominal Payments
23. Nominal Payments (American Rescue Plan Act funding only)
24. Nominal Payments (American Rescue Plan Act funding)
25. Nominal Payments (Reserved for other supplemental funding)
II. Number of Assisted Households by Poverty Interval
Applicable HHS Poverty Guidelines in effect at the beginning of FFY
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)
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. Crisis
a. Year Round
b. Year Round (CARES Act funding)
c. Year Round (American Rescue Plan Act funding)
d. Year Round (Reserved for other supplemental funding)
e. Winter
f. Winter (CARES Act funding)
g. Winter (American Rescue Plan Act funding)
h. Winter (Reserved for other supplemental funding)
i. Summer
j. Summer (CARES Act funding)
k. Summer (American Rescue Plan Act funding)
l. Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair & Replacement
n. Emergency Furnace Repair & Replacement (CARES Act funding)
o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)
p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
q. Other Crisis Assistance
r. Other Crisis Assistance (CARES Act funding)
s. Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance (Reserved for other supplemental funding)
10. Weatherization
11. Weatherization (CARES Act funding)
12. Weatherization (American Rescue Plan Act funding)
13. 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)
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. Crisis
a. Year Round
b. Year Round (CARES Act funding)
c. Year Round (American Rescue Plan Act funding)
d. Year Round (Reserved for other supplemental funding)
e. Winter
f. Winter (CARES Act funding)
g. Winter (American Rescue Plan Act funding)
h. Winter (Reserved for other supplemental funding)
i. Summer
j. Summer (CARES Act funding)
k. Summer (American Rescue Plan Act funding)
l. Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair & Replacement
n. Emergency Furnace Repair & Replacement (CARES Act funding)
o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)
p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
q. Other Crisis Assistance
r. Other Crisis Assistance (CARES Act funding)
s. Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance (Reserved for other supplemental funding)
10. Weatherization
11. Weatherization (CARES Act funding)
12. Weatherization (American Rescue Plan Act funding)
13. Weatherization (Reserved for other supplemental funding)
14. Any type of LIHEAP assistance
15. Any type of LIHEAP assistance (CARES Act funding)
16. Any type of LIHEAP assistance (American Rescue Plan Act funding)
17. Any type of LIHEAP assistance (Reserved for other supplemental funding)
IV. 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)
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. Crisis
a. Year Round
b. Year Round (CARES Act funding)
c. Year Round (American Rescue Plan Act funding)
d. Year Round (Reserved for other supplemental funding)
e. Winter
f. Winter (CARES Act funding)
g. Winter (American Rescue Plan Act funding)
h. Winter (Reserved for other supplemental funding)
i. Summer
j. Summer (CARES Act funding)
k. Summer (American Rescue Plan Act funding)
l. Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair & Replacement
n. Emergency Furnace Repair & Replacement (CARES Act funding)
o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)
p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)
q. Other Crisis Assistance
r. Other Crisis Assistance (CARES Act funding)
s. Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance (Reserved for other supplemental funding)
10. Weatherization
11. Weatherization (CARES Act funding)
12. Weatherization (American Rescue Plan Act funding)
13. Weatherization (Reserved for other supplemental funding)
V. Number of Assisted Households Owner/Renter Status
A. Owner/Renter Status	Total Number of Households
1. Own
2. Rent with utilities billed separately
3. Rent with utilities in rental fee
4. Other
4. TOTAL (Auto Calculated)	0
VI. Number of Assisted Household Applicants by Race and Ethnicity
A. Ethnicity	Total Number of Households
1. Hispanic, Latino, or Spanish Origins
2. Not Hispanic, Latino, or Spanish Origins
3. Unknown/not reported
4. TOTAL (Auto Calculated)	0
B. Race	Total Number of Households
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
VII. Number of Assisted Household Applicants by Gender	Total Number of Households
1. Self Identified Male
2. Self Identified Female
3. Other
4. Unknown/not reported
5. 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
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: