1 Household Report Short Form

OMB Clearance No.: 0970-0060 Expiration Date: 03/31/2026 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-SHORT FORM
Recipient Name:			FFY: 2024 (10/01/2023 - 09/30/2024)
Contact Person:			Phone:
Email Address:
The LIHEAP Household Report-Short Form is for use by all direct-grant tribes/tribal organizations.

Required Data

I. Ty pe of assistance ^{A. Number of assisted}

households

1. 

   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0
   0

   
   

   Heating

2. Heating (Coronavirus Aid, Relief, and Economic Security Funding)

3. Heating (American Rescue Plan Act funding)

4. Heating (Reserved for other supplemental funding)

5. Cooling

6. Cooling (Coronavirus Aid, Relief, and Economic Security 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 (Coronavirus Aid, Relief, and Economic Security 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 (Coronavirus Aid, Relief, and Economic Security Funding)

15. Summer crisis (American Rescue Plan Act funding)

16. Summer crisis (Reserved for other supplemental funding)

17. Weatherization

18. Weatherization (Coronavirus Aid, Relief, and Economic Security Funding)

19. Weatherization (American Rescue Plan Act funding)

20. Weatherization (Reserved for other supplemental funding)

Other crisis assistance Other crisis assistance (Coronavirus Aid, Relief, and Economic Security Funding) Other crisis assistance (American Rescue Plan Act funding) Other crisis assistance (Reserved for other supplemental funding)	0
	0
	0
	0
II. Number of Assisted Households Owner/Renter Status
A. Owner/Renter Status Own Rent with utilities billed separately Rent with utilities in rental fee Other Unknown/not Reported TOTAL	Total Number of Households
	0
	0
	0
	0
	0
	0
III. Number of Assisted Household Applicants by Race and Ethnicity

1. _Ethnicity Total Number of

Households

1. 

   0
   0
   0
   0

   
   

   Hispanic, Latino, or Spanish Origins

2. Not Hispanic, Latino, or Spanish Origins

3. Unknown/not reported

4. 

   Total Number of Households
   0
   0
   0
   0
   0
   0
   0
   0
   0

   
   

   TOTAL

2. Race

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

IV. Number of Assisted Household Applicants by Sex	Total Number of Households
Male Female Unknown/not reported TOTAL	0
	0
	0
	0
	0

V. Assisted Household Members by Race and Ethnicity
A. Ethnicity Hispanic, Latino, or Spanish Origins Not Hispanic, Latino, or Spanish Origins Unknown/not reported TOTAL B. Race American Indian or Alaska Native Asian	Number of Household Members
	0
	0
	0
	0
	Number of Household Members
	0
	0

Black or African American Native Hawaiian or Other Pacific Islander White Multi-race (two or more of the above) Other Unknown/not reported TOTAL	0
	0
	0
	0
	0
	0
	0
VI. Assisted Household Members by Sex	Number of Household Members
Male Female Unknown/not reported TOTAL	0
	0
	0
	0
	0
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 penalties. (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:

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