Information Collection

Low Income Home Energy Assistance (LIHEAP) Leveraging Report

IC 9857 under ICR 201703-0970-004 · OMB 0970-0121.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Low Income Home Energy Assistance (LIHEAP) Leveraging Report	Form
levinstr.doc Leveraging Report Instruction s	Instruction
1 LIHEAP Leveraging Report levform.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	LIHEAP Leveraging Report	levform.doc		Yes	Yes	Fillable Printable
Instruction			levinstr.doc	Leveraging Report Instruction s	Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	2,660	2,660
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.