Form 1 Detailed Model Plan

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)

DETAILED MODEL PLAN

PUBLIC LAW 97-35, AS AMENDED

FISCAL YEAR (FY) __________

GRANTEE _______________________________________________________ __ _

EIN: _______________________________________________________ ____ __

ADDRESS _____________________________________________________ _____ ___

__________________________________________________________ ____

______________________________________________________ ____

NAME OF LIHEAP COORDINATOR____________________________ _________ __

EMAIL: ___________________________________________________________ ____

TELEPHONE: FAX: _____________________ _______

PLEASE CHECK ONE: TRIBE __ STATE __ INSULAR AREA _____

Department of Health and Human Services

Administration for Children and Families

Office of Community Services

Washington, DC 20447

OMB Approval No. 0970-0075

Expiration Date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Use of this model plan is optional. However, the information requested is required in order to receive a Low Income Home Energy Assistance Program (LIHEAP) grant in years in which the grantee is not permitted to file an abbreviated plan. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

GRANTEE FFY _____________

Assurances

The agrees to:

(Grantee Name)

(1) use the funds available under this title to--

(A) conduct outreach activities and provide assistance to low income households in meeting their home energy costs, particularly those with the lowest incomes that pay a

high proportion of household income for home energy, consistent with paragraph (5);

(B) intervene in energy crisis situations;

(C) provide low-cost residential weatherization and other cost-effective energy-related home repair; and

(D) plan, develop, and administer the State's program under this title including leveraging programs,

and the State agrees not to use such funds for any purposes other than those specified in this title;

(2) make payments under this title only with respect to--

(A) households in which one or more individuals are receiving--

(i) assistance under the State program funded under part A of title IV of the Social Security Act;

(ii) supplemental security income payments under title XVI of the Social Security Act;

(iii) food stamps under the Food Stamp Act of 1977; or

(iv) payments under section 415, 521, 541, or 542 of title 38, United States Code, or under section 306 of the Veterans' and Survivors' Pension Improvement Act of 1978; or

(B) households with incomes which do not exceed the greater of—

(i) an amount equal to 150 percent of the poverty level for such State; or

(ii) an amount equal to 60 percent of the State median income;

except that a State may not exclude a household from eligibility in a fiscal year solely on the basis of household income if such income is less than 110 percent of the poverty level for such State, but the State may give priority to those households with the highest home energy costs or needs in relation to household income.

(3) conduct outreach activities designed to assure that eligible households, especially households with elderly individuals or disabled individuals, or both, and households with high home energy burdens, are made aware of the assistance available under this title, and any similar energy-related assistance available under subtitle B of title VI (relating to community services block grant program) or under any other provision of law which carries out programs which were administered under the Economic Opportunity Act of 1964 before the date of the enactment of this Act;

(4) coordinate its activities under this title with similar and related programs administered by the Federal Government and such State, particularly low-income energy-related programs under subtitle B of title VI (relating to community services block grant program), under the supplemental security income program, under part A of title IV of the Social Security Act, under title XX of the Social Security Act, under the low-income weatherization assistance program under title IV of the Energy Conservation and Production Act, or under any other provision of law which carries out programs which were administered under the Economic Opportunity Act of 1964 before the date of the enactment of this Act;

(5) provide, in a timely manner, that the highest level of assistance will be furnished to those households which have the lowest incomes and the highest energy costs or needs in relation to income, taking into account family size, except that the State may not differentiate in implementing this section between the households described in clauses 2(A) and 2(B) of this subsection;

(6) to the extent it is necessary to designate local administrative agencies in order to carry out the purposes of this title, to give special consideration, in the designation of such agencies, to any local public or private nonprofit agency which was receiving Federal funds under any low-income energy assistance program or weatherization program under the Economic Opportunity Act of 1964 or any other provision of law on the day before the date of the enactment of this Act, except that—

(A) the State shall, before giving such special consideration, determine that the agency involved meets program and fiscal requirements established by the State; and

(B) if there is no such agency because of any change in the assistance furnished to programs for economically disadvantaged persons, then the State shall give special consideration in the designation of local administrative agencies to any successor agency which is operated in substantially the same manner as the predecessor agency which did receive funds for the fiscal year preceding the fiscal year for which the determination is made;

(7) if the State chooses to pay home energy suppliers directly, establish procedures to --

(A) notify each participating household of the amount of assistance paid on its behalf;

(B) assure that the home energy supplier will charge the eligible household, in the normal billing process, the difference between the actual cost of the home energy and the amount of the payment made by the State under this title;

(C) assure that the home energy supplier will provide assurances that any agreement entered into with a home energy supplier under this paragraph will contain provisions to assure that no household receiving assistance under this title will be treated adversely because of such assistance under applicable provisions of State law or public regulatory requirements; and

(D) ensure that the provision of vendor payments remains at the option of the State in consultation with local grantees and may be contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible households, including providing for agreements between suppliers and individuals eligible for benefits under this Act that seek to reduce home energy costs, minimize the risks of home energy crisis, and encourage regular payments by individuals receiving financial assistance for home energy costs;

8. provide assurances that,

(A) the State will not exclude households described in clause (2)(B) of this subsection from receiving home energy assistance benefits under clause (2), and

(B) the State will treat owners and renters equitably under the program assisted under this title;

(9) provide that--

(A) the State may use for planning and administering the use of funds under this title an amount not to exceed 10 percent of the funds payable to such State under this title for a fiscal year; and

(B) the State will pay from non-Federal sources the remaining costs of planning and administering the program assisted under this title and will not use Federal funds for such remaining cost (except for the costs of the activities described in paragraph (16));

(10) provide that such fiscal control and fund accounting procedures will be established as may be necessary to assure the proper disbursal of and accounting for Federal funds paid to the State under this title, including procedures for monitoring the assistance provided under this title, and provide that the State will comply with the provisions of chapter 75 of title 31, United States Code (commonly known as the "Single Audit Act");

(11) permit and cooperate with Federal investigations undertaken in accordance with section 2608;

(12) provide for timely and meaningful public participation in the development of the plan described in subsection (c);

(13) provide an opportunity for a fair administrative hearing to individuals whose claims for assistance under the plan described in subsection (c) are denied or are not acted upon with reasonable promptness; and

(14) cooperate with the Secretary with respect to data collecting and reporting under section 2610.

(15) * beginning in fiscal year 1992, provide, in addition to such services as may be offered by State Departments of Public Welfare at the local level, outreach and intake functions for crisis situations and heating and cooling assistance that is administered by additional State and local governmental entities or community-based organizations (such as community action

agencies, area agencies on aging and not-for-profit neighborhood-based organizations), and in States where such organizations do not administer functions as of September 30, 1991, preference in awarding grants or contracts for intake services shall be provided to those agencies that administer the low-income weatherization or energy crisis intervention programs.

* This assurance is applicable only to States, and to territories whose annual regular LIHEAP allotments exceed $200,000. Neither territories with annual allotments of $200,000 or less nor Indian tribes/tribal organizations are subject to Assurance 15.

(16) use up to 5 percent of such funds, at its option, to provide services that encourage and enable households to reduce their home energy needs and thereby the need for energy assistance, including needs assessments, counseling, and assistance with energy vendors, and report to the Secretary concerning the impact of such activities on the number of households served, the level of direct benefits provided to those households, and the number of households that remain unserved.

Certification to the Assurances: As Chief Executive Officer, I agree to comply with the sixteen assurances contained in Title XXVI of the Omnibus Budget Reconciliation Act of 1981, as amended.* By signing these assurances, I also agree to abide by the standard assurances on lobbying, debarment and suspension, and a drug-free workplace.

Signature of the Tribal or Board Chairperson or Chief Executive Officer of the State or Territory.**

Signature: ______________________________________________________

Title ______________________________________________________

Date: ______________________________________________________

* Indian tribes/tribal organizations, and territories with annual regular LIHEAP allotments of $200,000 or less, are not subject to assurance 15, and thus must only certify to 15 assurances.

** If a person other than the Chief Executive Officer of the State or territory, or Tribal Chairperson or Board Chairperson of a tribal organization, is signing the certification to the assurances, a letter must be submitted delegating such authority. (PLEASE ATTACH DELEGATION of AUTHORITY.) The delegation must include authority to sign the assurances, not just to administer the program.

*** HHS needs the EIN (Entity Identification Number) of the State, territory or Tribal agency that is to receive the grant funds before it can issue the grant.

In the above assurances which are quoted from the law, "State" means the 50 States, the District of Columbia, an Indian Tribe or Tribal Organization, or a Territory; "title" of the Act refers to Title XXVI of the Omnibus Budget Reconciliation Act of 1981 (OBRA), as amended, the "Low Income Home Energy Assistance Act"; "section" means Section 2605 of OBRA; and, "subsection" refers to Section 2605(b) of OBRA.

GRANTEE FFY _______

statutory

references

2605(a)

2605(b)(1) Please check which components you will operate under the LIHEAP program. (Note: You must provide information for each component designated here as requested elsewhere in this plan.)

Dates of Operation

(use of

funds) heating assistance _________________________

cooling assistance _________________________

crisis assistance _________________________

weatherization assistance _________________________

2605(c)(l)(C) Please estimate what amount of available LIHEAP funds will be used for each component that you will operate: The total of all percentages must add up to 100%.

(use of

funds)

% heating assistance

% cooling assistance

% crisis assistance

2605(k)(1) % weatherization assistance

% carryover to the following fiscal year

2605(b)(9) % administrative and planning costs

2605(b)(16) % services to reduce home energy needs

including needs assessment (assurance 16)

% used to develop and implement leveraging activities (limited to the greater of 0.08% or $35,000 for States, the greater of 2% or $100 for territories, tribes and tribal organizations).

TOTAL

GRANTEE FFY ___________

statutory

references

2605(c)(1)(C) The funds reserved for winter crisis assistance that have not been expended by March 15 will be reprogrammed to:

(alternate use

of crisis assistance

funds) heating assistance

cooling assistance

weatherization assistance

Other(specify):

Do you accept applications for energy crisis assistance at sites that are geographically accessible to all households in the area to be served? (This is required by the statute.)

Yes No _______

2605(b)(2) What are your maximum eligibility limits?

2605(c)(1)(A) (Please check the components to which they apply.)

Current year guidelines must be used.

(eligibility) 150% of the poverty guidelines:

heating cooling crisis wx __

125% of the poverty guidelines:

heating cooling crisis wx

110% of the poverty guidelines:

heating cooling crisis wx _

60% of the State's median income:

heating cooling crisis wx

Other (specify for each component)

___________________________________________________

Households automatically eligible if one person is receiving

TANF, ____SSI, Food Stamps, Certain means-tested veterans programs (heating cooling crisis wx )

GRANTEE FFY __________

statutory

references

2605(c)(1)(A) Do you have additional eligibility requirements for:

2605(b)(2) HEATING ASSISTANCE Yes No)

(eligibility)

Do you use: Yes No

Assets test? _____ _____

Do you give priority in eligibility to:

Elderly? _____ _____

Disabled? _____

Young children? _____

Other: _____

(If Yes, please describe)

GRANTEE _ FFY ___________

statutory

references

2605(c)(1)(A)

2605(b)(2) Do you have additional eligibility requirements for:

COOLING ASSISTANCE ( Yes No)

(eligibility)

Do you use: Yes No

Assets test? ______ ______

Do you give priority in eligibility to:

Elderly? ______ ______

Disabled? ______ ______

Young children? ______ ______

Other: ______ ______

(If Yes, please describe)

GRANTEE FFY ___________

statutory

references

2604(c)

2605(c)(1)(A) Do you have additional eligibility requirements for:

CRISIS ASSISTANCE ( Yes No)

(eligibility)

Yes No

Do you use:

Assets test? ______ ______

Must the household have received a
shut-off notice or have an empty tank? ______ ______

Must the household have exhausted
regular benefit? ______ ______

Must the household have received a
rent eviction notice? ______ ______

Must heating/cooling be medically
necessary? ______ ______

Other (Please explain): ______ ______

What constitutes a crisis? (Please describe)

GRANTEE FFY ______________

statutory

references

2605(c)(1)(A) Do you have additional eligibility requirements for: WEATHERIZATION ( Yes No)

(eligibility)

Do you use: Yes No

Assets test? _____ _____

Priority groups? (Please list)

Are you using Department of Energy (DOE) Low Income Weatherization Assistance Program (LIWAP) rules to establish eligibility or to establish priority eligibility for households with certain characteristics? _____ _____

If Yes, are there exceptions? _____

Please list below.

GRANTEE FFY ___________

statutory

references

2605(b)(3) Please check the outreach activities that you

2605(c)(3)(A) conduct that are designed to assure that eligible households are made aware of all LIHEAP assistance available:

(outreach)

provide intake service through home visits or by telephone for the physically infirm (i.e. elderly or disabled).

place posters/flyers in local and county social service offices, offices of aging, Social Security offices, VA, etc.

publish articles in local newspapers or broadcast media announcements.

include inserts in energy vendor billings to inform individuals of the availability of all types of LIHEAP assistance.

make mass mailing to past recipients of LIHEAP.

inform low income applicants of the availability of all types of LIHEAP assistance at application intake for other low‑income programs.

execute interagency agreements with other low‑income program offices to perform outreach to target groups.

other (Please specify):

GRANTEE FFY _________

statutory

references

2605(b)(4) Please describe how you will assure that LIHEAP is coordinated with similar and related programs. The description provided applies to all components unless specifically noted.

(coordination)

2605(b)(5) The statute requires that there be no difference in the treatment

2605(b)(2) of households eligible because of their income and those eligible

2605(b)(8A) because they receive benefits under TANF, Food Stamps, SSI, or certain means-tested veterans programs ("categorically eligible"). How do you ensure there is no difference when determining eligibility and benefit amounts? This applies to all components unless specifically noted below.

(benefit

levels)

GRANTEE FFY ______

statutory

references

HEATING COMPONENT

2605(b)(5) Please check the variables you use to determine your benefit levels (check all that apply):

(determination

of benefits)

income

family (household) size

home energy cost or need

____fuel type

climate/region

____individual bill

dwelling type

energy burden

(% of income spent on home energy)

energy need

other (describe)

2605(b)(5) Describe how you will assure that the highest benefits go to households

2605(c)(1)(B) with the lowest incomes and the highest energy costs or needs in relation to income, taking into account family size.

(benefit Please describe benefit levels or attach a copy of your payment matrix.

levels)

Do you provide in-kind (e.g., blankets, space heaters) and/or other forms of benefits?

Yes No If Yes, please describe.

GRANTEE FFY _____

statutory

references

2605(b)(5) COOLING COMPONENT

2605(c)(1)(B)

Please check the variables you use to determine your benefit levels (check all that apply):

(determination

of benefits)

income

family (household) size

home energy cost or need

fuel type

climate/region

individual bill

dwelling type

energy burden

(% of income spent on home energy)

energy need

other (describe)

2605(b)(5) Describe how you will assure that the highest

2605(c)(1)(B) benefits will go to households with the lowest

incomes and the highest energy costs or needs

(benefit in relation to income, taking into account family size. Please describe levels) benefit levels or attach a copy of your payment matrix.

Do you provide in-kind (e.g. fans) and/or other forms of benefits?

Yes No If Yes, please describe.

GRANTEE FFY _________

statutory

references

2605(b)(5) CRISIS COMPONENT

2605(c)(1)(B)

(determination

of benefits)

How do you handle crisis situations?

separate component other (please explain)

If you have a separate component, how do you determine crisis assistance benefits?

amount to resolve crisis, up to maximum

other (please describe)

(benefit

levels) Please indicate the maximum benefit for each type of crisis assistance offered.

heating $ maximum benefit

cooling $ maximum benefit

year-round $ maximum benefit

Do you provide in-kind (e.g. blankets, space heaters, fans) and/or other forms of benefits?

Yes No If Yes, please describe.

GRANTEE FFY ____________

statutory

references

2605(b)(5) WEATHERIZATION & OTHER ENERGY RELATED

2605(c)(1) HOME REPAIR AND IMPROVEMENTS

(B) & (D)

What LIHEAP weatherization services/materials do you provide? (Check all categories that apply.)

(types of Weatherization needs assessments/audits.

assistance) Caulking, insulation, storm windows, etc.

Furnace/heating system modifications/repairs

Furnace replacement

Cooling efficiency mods/repairs/replacement

Other (Please describe)

(benefit Do you have a maximum LIHEAP weatherization benefit/expenditure levels) per household? Yes No

If Yes, what is the maximum amount? $______________

Under what rules do you administer LIHEAP weatherization? (Check only one.)

(types of Entirely under LIHEAP (not DOE) rules

rules) Entirely under DOE LIWAP rules

Mostly under LIHEAP rules with the following DOE LIWAP rule(s) where LIHEAP and LIWAP rules differ (Check all that apply):

Weatherize buildings if at least 66% of units (50% in 2- & 4-unit buildings) are eligible units or will become eligible within 180 days
Weatherize shelters temporarily housing primarily low income persons (excluding nursing homes, prisons, and similar institutional care facilities).
Other (Please describe)

Mostly under DOE LIWAP rules, with the following LIHEAP rule(s) where LIHEAP and LIWAP rules differ (Check all that apply.)

Weatherization not subject to DOE LIWAP maximum statewide average cost per dwelling unit.
Other (Please describe.)

GRANTEE FFY _________

2605(b)(6) The state or tribe administers LIHEAP through the following local agencies:

_____ county welfare offices

_____ community action agencies (weatherization component only)

_____ community action agencies (heating, cooling or crisis

(agency _____ charitable organizations

designation) _____ not applicable (i.e. state energy office)

_____ tribal office

_____ other, describe:

Have you changed local administering agencies from last year?

Yes No

If Yes, please describe how you selected them.

What components are affected by the change?

2605(c)(1)(E) Please describe any additional steps (other than those described elsewhere in this plan) that will be taken to target assistance to households with high home energy burdens. (This applies to all components. If all steps to target households with high home energy burdens are described elsewhere in the plan, no further information is required here.)

(targeting of

assistance)

GRANTEE FFY ________

statutory

references

2605(b)(7) Do you make payments directly to home energy suppliers?

(energy

suppliers) Heating Yes No

Cooling Yes No

Crisis Yes No

If Yes, are there exceptions? Yes No

If Yes, please describe.

2605(b)(7)(A) If you make payments directly to home energy suppliers, how do you notify the client of the amount of assistance paid? (Please describe)

2605(b)(7)

(B) & (C)

How do you make sure the home energy supplier performs what is required in this assurance? If vendor agreements are used, they may be attached. Indicate each component for which this description applies.

GRANTEE FFY _________

statutory

references

2605(b)(8)(B) Is there any difference in the way owners and renters are treated? If Yes, please describe.

(owners HEATING ASSISTANCE

and

renters) Yes No

COOLING ASSISTANCE

Yes No

CRISIS ASSISTANCE

Yes No

WEATHERIZATION

Yes No

GRANTEE FFY ________

statutory

references

2605(b)(10) How do you ensure good fiscal accounting and tracking of LIHEAP funds? (Please describe. Include a description of how you monitor fiscal activities.)

(program,

fiscal

monitoring,

and audit)

How do you monitor program activities? (Please be sure to include a description of how you monitor eligibility and benefit determination.)

How is your LIHEAP program audited?

Under the Single Audit Act? Yes No

If not, please describe:

For States and Territories:

Is there an annual audit of local administering agencies? Yes No

If not, please explain.

GRANTEE FFY _________

statutory

references

2605(b)(12) How did you get timely and meaningful public participation in the development of the plan? (Please describe.)

(timely and

meaningful

public

partici-

pation)

2605(a)(2) Did you conduct public hearings on the proposed use and distribution of your LIHEAP funds? When and where?

_____Yes ____No

(Not required for Tribes and tribal organizations)

(public

hearings)

GRANTEE FFY ____________

statutory

references

2605(b)(13) Describe your fair hearing procedures for households whose applications are denied or not acted on in a timely manner. When are applicants informed of these rights?

(fair

hearings)

Denials

Applications Not Acted On In a Timely Manner

GRANTEE FFY __________

statutory

references

2605(b)(15) For States and Puerto Rico only (not applicable to Tribes and tribal organizations, or to territories whose annual regular LIHEAP allotments are $200,000 or less):

Does the State agency that administers the following LIHEAP component also administer the State's welfare program?

(alternate

outreach

and intake) HEATING ASSISTANCE

Yes No

If Yes, describe alternate process for outreach and intake:

COOLING ASSISTANCE

Yes No

If Yes, describe alternate process for outreach and intake:

CRISIS ASSISTANCE

Yes No

If Yes, describe alternate process for outreach and intake:

GRANTEE FFY _______

statutory

references

2605(b)(16) Do you use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and thereby the need for energy assistance? (This assurance refers to activities such as needs assessments, counseling, and assistance with energy vendors.)

Yes No

If Yes, please describe these activities.

If Yes, how do you ensure that you don't use more than 5% (statutory ceiling) of your LIHEAP funds for these activities?

GRANTEE __ FFY ________

statutory

references

2607A Please describe leveraging activities planned for the fiscal year. (This entry is optional.*) Complete this entry if you plan to apply for

(leveraging) LIHEAP leveraging incentive funds and to include in your leveraging report resources/benefits provided to low income households this fiscal year under criterion (iii) in 45 CFR 96.87(d)(2). Provide the following information for each:

(1) Identify and described each resource/benefit;

(2) Identify the source(s) of each resource; and

(3) Describe the integration/coordination of each resource/benefit with the LIHEAP program, consistent with 1 or more of conditions A-H in 45 CFR 96.87(d)(2)(iii).

* Leveraged resources/benefits that are counted under criterion (iii) in 45 CFR 96.87(d)(2) must be identified and described in the grantee's LIHEAP plan and distributed as indicated in the plan. In addition, leveraging resources/benefits that are counted under criterion (ii) must be carried out under one or more components of the grantee's regular LIHEAP program.

GRANTEE FFY _____

statutory

references

2605(b) Please describe performance goals and measures planned for the fiscal year. (This entry is optional.)

(performance)

goals and

measures)

ADDITIONAL CERTIFICATIONS AND REQUIREMENTS

Attached are additional certifications required as follows:

* Lobbying certification, which must be filed by all States and territories. If applicable, Form LLL, which discloses lobbying payments, must be submitted. (Tribes and tribal organizations are EXEMPT.)

* Debarment and suspension certification, which must be filed by all grantees.

* Drug-free workplace requirement certification, which must be filed by all grantees, unless the grantee has filed a statewide certification with the Department of Health and Human Services. STATES ONLY: If you have filed a statewide certification for the drug-free workplace requirement, please check here:

* One of the requirements included in the 1994 reauthorization of the statute is that state grantees must include in their annual application for funds a report on the number and income levels of households applying for and receiving LIHEAP assistance, and on the number of recipient households that have members who are elderly, disabled, or young children.

All Tribes and those territories with allotments of less than $200,000 need only submit data on the number of households served by each component (heating, cooling, weatherization and crisis). The approval for the collection of information contained in the LIHEAP Household Report is covered by OMB approval number 0970-0060.

* Though not a part of this application, the report on funds to be carried over or available for reallotment as required by section 2607(a) for the preceding year must be submitted by August 1 of each year. A grant award for the current fiscal year may not be made until the carryover/reallotment report is received. The approval for the collection of information contained in the LIHEAP Carryover and Reallotment Report is covered by OMB approval number 0970-0106.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 1 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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