Weatherization Assistance Program Evaluation

OMB Control Number: __ __ __ __ - __ __ __ __

DF4: ELECTRIC AND NATURAL GAS BILLS: INFORMATION FROM AGENCIES FORM

This data form collects detailed information about single family and multi-family homes weatherized (or waitlisted) by your agency in Program Years 2007, 2008 and 2009. The data you supply will be used to characterize the program and collect utility billing histories pre- and post-weatherization to better understand energy savings attributable to the Weatherization Assistance Program.

Public reporting burden for this collection of information is estimated to average thirty-two hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-11, Paperwork Reduction Project (1910-XXXX), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-XXXX), Washington, DC  20503.

All of the information obtained from this survey and from utilities will be protected and will remain confidential. The data will be analyzed in such a way that the information provided cannot be associated back to your state, your agencies, or the housing units and clients that your state served.

Requested Initial Information: Part A of Sections 2 and 3

We would like to collect electricity and natural gas billing data on a number of housing units served by your agency. To help us randomly select a sample of weatherized units, please use Part A in Sections 2 and 3 of this form to provide the job numbers and building type for all the housing units that you weatherized in Program Years 2007, 2008 and 2009 and homes on your waiting list for Program Year 2009. If you store the necessary housing unit data (job number, building type, utility name, utility account number, and weatherization date) in an electronic format, then all units will be selected.

Additional Information: Part B of Section 2 and Part B and C of Section 3

Once we have selected a sample from your list of clients, we will ask you to complete Part B in Section 2 and Parts B and C in Section 3 to provide additional information for each of the selected units, including utility account numbers, fuel release forms and weatherization dates. This information will support the collection of utility billing data for sampled units. Agencies can choose to provide the information requested in Parts B and C now for all units, or submit the information requested in Parts B and C for sampled units only after those units have been identified in a subsequent data request. Please note that Part B requires copies of all utility billing data release forms to be attached.

Utility Information: Section 4

Please provide contact information for each utility listed in Sections 2 and 3.

Section 1. Agency Information

Agency name: _______________________________

Contact name: _______________________________

State: ______________________________________

Date: ______________________________________

Does your agency have an electronic database with all of the data you keep on weatherized units?

• Yes

• No

Section 2. Weatherized and Waitlisted Single Family Housing Units: PY 2007-2009

In Part A (columns A through G), please provide the requested information for all the single family housing units that your agency weatherized in PY 2007-2009, as well as all units that are currently waitlisted for PY 2009. Part B (columns H through P) includes additional information that will be requested for sampled units. Agencies can submit the information requested in Part B now for all units, or submit the information requested in Part B later for sampled units only after those units have been identified in a subsequent data request. The first line contains an example.

Part A Requested Data: Complete now for all units Part B Additional Information: Complete now for all units or complete later for sampled units only

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Job Number

Program Year

Building Type SFA: single family attached SFD: single family detatched MH: mobile home

Utility Name

Primary Heating Fuel: EL: electricity NG: natural gas LP: propane FO: fuel oil WO: wood OT: other

Job Status W: waitlisted I: in progress C: completed

Address

Weatherization Date

Utility Account Numbers

Utility Billing Data Release Y: yes (please attach) N: don’t have

Electric

Natural Gas

Street Number

Street Name

City

Zip

Start

End

Electricity

Natural Gas

1234

2007

SFA

Xcel

CenterPoint

NG

C

255

Green St

Winthrop

55396

8/1/07

10/15/07

100058000

254000649

Y

Section 2, additional pages. Weatherized and Waitlisted Single Family Housing Units: PY 2007-2009

Please make as many copies of this page as needed to submit requested information for all single family housing units weatherized in PY 2007-2009 and waitlisted in PY 2009.

Part A Requested Data continued: Complete now for all units Part B Additional Information cont.: Complete now for all units or complete later for sampled units

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Job Number

Program Year

Building Type SFA: single family attached SFD: single family detatched MH: mobile home SH: shelter

Utility Name

Primary Heating Fuel: EL: electricity NG: natural gas LP: propane FO: fuel oil WO: wood OT: other

Job Status W: waitlisted I: in progress C: completed

Address

Weatherization Date

Utility Account Number

Utility Billing Data Release Y: yes (please attach) N: don’t have

Electric

Natural Gas

Street Number

Street Name

City

Zip

Start

End

Electricity

Natural Gas

Section 3. Weatherized and Waitlisted Multi-Family Housing Units: PY 2007-2009

In Part A (columns A through I), please provide the requested information for all the multi-family housing units that your agency weatherized in each Program Year, as well as all units that are currently waitlisted.

Part B (columns J through AA) includes additional information that will be requested for sampled units. Part C (columns A through J) includes information that will be requested for sampled buildings that have building-level electric and/or natural gas meters. Agencies can submit the information requested in Parts B and C now for all units/buildings, or submit the information requested in Parts B and C later for sampled units/buildings only after those units/buildings have been identified in a subsequent data request.

If multiple units in a building were weatherized or waitlisted, agencies can reduce data entry burdens by entering information for a single unit within that building in Parts A and B, and then indicating the remaining number of weatherized/waitlisted units in the building by skipping the equivalent number of rows (see example below).

Part A Requested Data: Complete now for all units Part B Additional Information: Complete now for all units or complete later for sampled units

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

Job Number

Program Year

Building Type: SU: Single unit weatherized in a MF building SMF: small multi- family (2-4 units) entirely weatherized LMF: large multi-family (5+ units) entirely weatherized

Number of Units

Utility Name

Primary Heating Fuel EL: electricity NG: natural gas LP: propane FO: fuel oil WO: wood OT: other

Job Status W: waitlisted I: in progress C: completed

Address

Head of Household Name

Weatherization Date

In Building

Weather-ized

Electric

Natural Gas

Street Number

Street Name

Unit Number

City

Zip

Start

End

6789

2007

SMF

4

4

Xcel

CenterPoint

NG

C

135

Center St

16

Winthrop

55396

Jane Doe

10/3/07

12/28/07

Skip

Skip

Skip

6790

2007

LMF

15

6

Xcel

CenterPoint

EL

C

899

Water St

5A

New Ulm

56073

Joe Smith

10/28/07

1/03/08

Section 3, continued. Weatherized Multi-Family Housing Units: PY 2007-2009

Part B Additional Information continued: Complete now for all units or complete later for sampled units only

R	S	T	U	V	W	X	Y	Z	AA
Job Number	Ownership O: owner (paid in full or mortgaged) R: renter P: occupied without payment D: don’t know	Unit Occupied by at Least One Person Who Is				Are there one or more building-level electric or gas meters? Y: yes (if so, please complete Part C) N: no	Utility Account Number (unit-level meters only)		Utility Billing Data Release Y: yes (please attach) N: don’t have
		Elderly (60 years or older) Y: yes N: no D: don’t know	Disabled Y: yes N: no D: don’t know	Native American Y: yes N: no D: don’t know	A Child (as defined by your state) Y: yes N: no D: don’t know		Electricity	Natural Gas
6789	R	Y	Y	N	N	Y	194650007	645509870	Y
Skip
Skip
Skip
6790	R	N	N	N	Y	N	455579120	655498001	Y

Part C includes information that will be requested for sampled buildings that have building-level electric and/or natural gas meters. If a building has multiple building-level electric or natural gas meters, use multiple rows to enter account information (see example). Agencies can submit the information requested in Part C now for all weatherized and waitlisted buildings with building-level meters, or submit the information requested in Part C later for sampled buildings only after those buildings have been identified in a subsequent data request.

Part C Additional Information: Complete now for all buildings with building-level electric or natural gas meters, or complete later for sampled buildings

A	B	C	D	E	F	G	H	I	J
	Address				Electricity		Natural Gas
Job Numbers	Street Number	Street Name	City	Zip	Utility Name	Utility Account Number (building-level meters only)	Utility Name	Utility Account Number (building-level meters only)	Utility Billing Data Release Y: yes (please attach) N: don’t have
6789	135	Center St	Winthrop	55396	Xcel Energy	487756907	CenterPoint	596882314	Y
6789	135	Center St	Winthrop	55396	Xcel Energy	487756921
6789	135	Center St	Winthrop	55396	Xcel Energy	487756930

Section 3, extra pages. Weatherized and Waitlisted Multi-Family Housing Units: PY 2007-2009

Please make as many copies of this page as needed to submit requested information for all multi-family housing units weatherized in PY 2007-2009 and waitlisted in PY 2009.

Part A Requested Data continued: Complete now for all units Part B Additional Information continued: Complete now for all units or complete later for sampled units

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

Job Number

Program Year

Building Type: SMF: small multi- family (2-4 units) LMF: large multi-family (5+ units) SH: shelter

Number of Units

Utility Name

Primary Heating Fuel EL: electricity NG: natural gas LP: propane FO: fuel oil WO: wood OT: other

Job Status W: waitlisted I: in progress C: completed

Address

Head of Household Name

Weatherization Date

In Building

Weather-ized

Electric

Natural Gas

Street Number

Street Name

Unit Number

City

Zip

Start

End

Section 3, extra pages. Weatherized and Waitlisted Multi-Family Housing Units: PY 2007-2009

Please make as many copies of this page as needed to submit requested information for all multi-family housing units weatherized in PY 2007-2009 and waitlisted in PY 2009.

Part B Additional Information continued: Complete now for all units or complete later for sampled units

R	S	T	U	V	W	X	Y	Z	AA
Job Number	Ownership O: owner (paid in full or mortgaged) R: renter P: occupied without payment D: don’t know	Unit Occupied by at Least One Person Who Is				Are there one or more building-level electric or gas meters? Y: yes (if so, please complete Part C) N: no	Utility Account Number (unit-level meters only)		Utility Billing Data Release Y: yes (please attach) N: don’t have
		Elderly (60 years or older) Y: yes N: no D: don’t know	Disabled Y: yes N: no D: don’t know	Native American Y: yes N: no D: don’t know	A Child (as defined by your state) Y: yes N: no D: don’t know		Electricity	Natural Gas

Section 3, extra pages. Weatherized and Waitlisted Multi-Family Housing Units: PY 2007-2009

Please make as many copies of this page as needed to submit requested information for buildings with building-level electric or natural gas meters.

Part C Additional Information continued: Complete now for all buildings with building-level electric or natural gas meters, or complete later for sampled buildings

A	B	C	D	E	F	G	H	I	J
	Address				Electricity		Natural Gas
Job Numbers	Street Number	Street Name	City	Zip	Utility Name	Utility Account Number (building-level meters only)	Utility Name	Utility Account Number (building-level meters only)	Utility Billing Data Release Y: yes (please attach) N: don’t have

Section 4. Utility Information

Please provide contact information for each utility listed in Sections 2 and 3.

				Type of Service
Utility Name	Address	Contact Name for Billing Data Inquiries (if known)	Contact Phone Number (if known)	Electric	Natural Gas

Building Type Definitions:

Single family detached house—House that provides living space for one family or household, is contained within walls that go from the basement (or the ground floor, if there is no basement) to the roof, and has no walls that are shared (or built in contact) with another household. A manufactured house assembled on site is a single family detached housing unit, not a mobile home.

Single family attached house—House that provides living space for one family or household, is contained within walls that go from the basement (or the ground floor, if there is no basement) to the roof, has at least one wall that is shared (or built in contact) with an adjacent household, and has an independent outside entrance. An attached house is not divided into more than one housing unit and does not have a household living above or below another one within the walls extending from the basement to the roof to separate any adjacent units. Examples include a house that is a side-by-side duplex, part of a townhouse building, and a row house.

Mobile home—Home that is built on a movable chassis, is moved to the site, and may be placed on a permanent or temporary foundation. If rooms are added to the structure, it is considered a mobile home if the added floor area is less than the mobile home’s original floor area; otherwise, it is a single family detached house. A manufactured house assembled on site is a single family detached house, not a mobile home.

Small multifamily—Building with two to four housing units (i.e., building that is divided into living quarters for two, three, or four families or households) in which one household lives above or beside another and does not meet the single family attached house definition. Includes houses originally intended for occupancy by one family (or for some other use) that have since been converted to separate dwellings for two to four families. Typical arrangements in these types of living quarters are separate apartments downstairs and upstairs or one apartment on each of three or four floors.

Large multifamily—Building with five or more housing units (i.e., building that contains living quarters for five or more families or households) that does not meet the single family attached house definition.

Shelter—Structure whose principal purpose is to house individuals on a temporary basis who may or may not be related to one another and who are not living in nursing homes, prisons, or similar institutional care facilities.