Weatherization Assistance Program ARRA-Period Evaluation

OMB Control Number: XXXX-XXXX

Expiration Date: MM/DD/YYYY

DF12 Weatherization Deferral Data Form

This information is being collected to help implement the Weatherization Deferral Study.

Public reporting burden for this collection of information is estimated to average 2 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.  All of the information obtained via this data form will be protected and will remain confidential. 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 ( ), 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 ( ), Washington, DC  20503.

Thank you in advance for completing this data form.

1. Please identify your local weatherization agency. _____________________________

2. Please provide the following information about each home for which weatherization was deferred at the audit stage during the period from the beginning of January 2011 to the end of March 2011. Please indicate whether the home was eventually weatherized by your agency. Please add additional rows as necessary. A data file can also be provided and transferred using our secure server.

CLIENT NAME	ADDRESS	PHONE NUMBER	Eventually Weatherized (Y/N)

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