Form 1 Long Format for Applicant

Low Income Home Energy Assistance Program (LIHEAP) Household Report

hhsrptst12_long form.xls

Long Format for Applicants

OMB: 0970-0060

Document [xlsx]
Download: xlsx | pdf
OMB Control No. 0970-0060
LIHEAP Household Report--Federal Fiscal Year 2012--Long Format
Expiration Date: 10/31/1x
Grantee Name:
Contact Person:
Phone:

Date:
















The LIHEAP Household Report--Long Format is for use by the 50 States, District of Columbia, and insular areas with annual LIHEAP allotments of $200,000 or more. This Federal Report provides data on both LIHEAP
recipient and applicant households for Federal Fiscal Year (FFY) 2012, the period of October 1, 2011 - September 30, 2012. The Report consists of the following sections: (1) Recommended Long Format for LIHEAP
Assisted Households and (2) Recommended Format for LIHEAP Applicant Households. Data on assisted households are included in the Department's annual LIHEAP Report to Congress. The data are also used in
measuring targeting performance under the Government Performance and Results Act of 1993. As the reported data are aggregated, the information in this report is not considered to be confidential.















There are two types of data: (1) required data which must be reported under the LIHEAP statute and (2) requested data which are optional, in response to House Report 103-483 and Senate Report 103-251. Both the
LIHEAP Household Report--Long Format (the Excel file name is hhsrptst.xls) and the instructions on completing the Report (the Word file name is hhrptins.doc) can be downloaded in the Forms sections of the Office of
Community Services' LIHEAP web site at: www.acf.hhs.gov/programs/ocs/liheap/grantees/forms.html#household_report . The spreadsheet is page protected in order to keep the format uniform. The items requiring a
response are not page protected. However, other areas of the spreadsheet cannot be modified. For example, the number of assisted and applicant households can not be entered. Each total will be calculated
automatically for each type of assistance by a formula when the poverty level data are entered.















Do the data below include estimated figures? No
Yes
Mark "X" in the second column below for each type of assistance that has at least one estimated data entry.















1. RECOMMENDED LONG FORMAT FOR LIHEAP ASSISTED HOUSEHOLDS


REQUIRED DATA
REQUESTED DATA
Type Mark "X" to indicate estimated data Number of 2011 HHS Poverty Guideline interval, based on gross income and household size At least one member who is
At least one member who is
of assisted Under 75%-100% 101%-125% 126%-150% Over 60 years or Disabled Age 5 years Elderly/Disabled/Young Child
Age 2 years Age 3 years
assistance households 75% poverty poverty poverty poverty 150% poverty older (elderly)
or under (young child)
or under through 5 years
Heating
0











Cooling
0











Winter/year round crisis
0










Summer crisis
0











Other crisis (specify)
0











Weatherization
0











Any type of LIHEAP assistance
0


























Note: Include any notes below for section 1 (indicate type of assistance and item the note is referencing):





= not applicable




















2. RECOMMENDED FORMAT FOR LIHEAP APPLICANT HOUSEHOLDS (regardless of whether assisted)




REQUIRED DATA





Type Mark "x" to indicate estimated data Number of 2011 HHS Poverty Guideline interval, based on gross income and household size





of applicant Under 75%-100% 101%-125% 126%-150% Over Income data





assistance households 75% poverty poverty poverty poverty 150% poverty unavailable





Heating
0











Cooling
0











Winter/year round crisis
0











Summer crisis
0











Other crisis (specify)
0











Weatherization
0


























Note: Include any notes below for section 1 or 2 (indicate which section, type of assistance, and item the note is referencing):





File Typeapplication/vnd.ms-excel
AuthorACF
Last Modified ByDepartment of Health and Human Services
File Modified2011-02-16
File Created1999-02-09

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