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Performance Data Form

ICR 201802-0970-007 · OMB 0970-0449 · Object 80894001.

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File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Title	Performance Data Form
Author	ACF;Verve
Last Modified By	Calc
File Modified	2014-06-04
File Created	2026-09-01
Conversion State	complete

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Grantee Name:

Date:

Contact Person:

Phone Number:

SECTION II. REPORTING REQUIREMENTS

The 50 States and the District of Columbia are required to complete the LIHEAP Grantee Survey in providing estimates of sources and uses of funds, average benefits, and the maximum income cutoff in dollars for a 4-person household as
of 10/1/1x for each type of LIHEAP assistance provided in FFY 201x.
Additionally, the 50 states and the District of Columbia are required to complete the LIHEAP Performance Measurement Form. This Federal Report provides data on three required LIHEAP Performance Measures for Federal Fiscal Year
(FFY) 201x, the period of October 1, 201x - September 30, 201x. The Report consists of the following sections: (1) Energy Burden Targeting, (2) Restoration of Home Energy Service, and (3) Prevention of Loss of Home Energy Service.
Timely response to questions on this report is mandatory. The information will be used to respond to Congressional inquiries, to calculate LIHEAP benefit targeting, and to provide Federal Fiscal Year data for the Department's annual LIHEAP
Report to Congress that is required under Section 2610 of Public Law 967-35, as amended. The data are also used in measuring LIHEAP performance under the Government Performance and Results Act (GPRA) of 1993, as amended by
the GPRA Modernization Act of 2010. As the reported data are aggregated, the information in this report is not considered to be confidential.

SECTION III. ESTIMATED SOURCES OF LIHEAP FUNDS
ALL OF FFY 201x (10/1/201x TO 9/30/201x)
Amount Rounded to the Nearest Dollar
A. All funds Except Leveraging Incentive Awards (Items 1-8)
1. FFY LIHEAP Block Grant Allotment (Net of Indian Tribal Set-Asides)

2. FFY Emergency Contingency Funds (Net of Indian Tribal Set-Asides)

3. LIHEAP Block Grant Funds Realloted to FFY

4. Previous FFY Unobligated Emergency Contingency Funds, not Subject to 10% Carryover Limit

5. Previous FFY Unobligated Leveraging Incentive Funds, not Subject to 10% Carryover Limit

6. All Funds Carried Over From Previous FFY (except Funds in item 4 and 10 in this Section)

7. Petroleum Violation Escrow (Oil Overcharge) Funds Obligated in FFY

8. FFY Residential Energy Assistance Challenge (REACH) Program

B. Leveraging Incentive Award (Items 9-10)
9. FFY Leveraging Incentive Award obligated in next FFY

10. Previous FFY Leveraging Incentive Award obligated in FFY

C. Estimated Total Sources of Funds (Items 1-10)
11. Sum of Items 1-10. This should equal the sum in Section IV. Column D, Item 13.

SECTION IV. ESTIMATED USES OF LIHEAP FUNDS
A. Type of LIHEAP Assistance (Items 1-4)

All of FFY 201x (10/1/201x) to 9/30/201x)
Amount Rounded to the Nearest Dollar
Total Funds/Awards

Average Household
Benefit

Maximum Annual Dollar Income for 4Person Household as of 10/1/1x

1. Heating Assistance Benefits

2. Cooling Assistance Benefits

$0
$0
$0
$0

$0
$0
$0

3. Crisis Benefits by Type:
a. Winter Crisis Benefits
b. Summer Crisis Benefits
c. Year-round Crisis Benefits
d. Other Crisis Benefits
(1) Specify:
(2) Specify:
(3) Specify:

$0
$0
$0

4. Weatherization Assistance Benefits

Bill Payment-Assisted Household Main Fuel

All Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)

5. Average Annual Total LIHEAP Benefit per Household (including Heating, Cooling, Crisis, Supplemental Benefits)
B. Other Permitted Uses of LIHEAP Funds (Items 6-14)

All Households

Electricity

Natural Gas

Fuel Oil

Propane

Other Fuels

6. Nominal Payments

7. FFY Unobligated Funds (excluding funds in Items 6 & 7) Carried Over to next FFY

8. FFY Allowable Unobligated Emergency Contingency Funds, not Subject to 10% Carryover Limit, Obligated in next FFY

9. FFY Leveraging Incentive Award Obligated in next FFY

10. FFY Emergency Contingency Funds Obligated in next FFY

11. FFY LIHEAP Block Grant Allotment Used to Identify, Develop & Demonstrate Leveraging Incentive Activities

12. Assurance 16 Activities

13. FFY Residential Energy Assistance Challenge (REACH) Program

14. Administration/Planning Costs

C. Estimated Total Uses of Funds (Items 1-4 and 6-14)

15. Sum of Items 1-4 and 6-14. This should equal the sum in Section III. Column D, Item 11.

Q1. Obligated funding for a given type of assistance in current FFY, but will serve households in the subsequent FFY

yes/no

Q2. Average Household Benefits are estimated due to unique program operation, rather than directly calculated

yes/no

Notes: Include any notes. Please indicate type of LIHEAP assistance and item being referenced.

LIHEAP Performance Measures
V. ENERGY BURDEN TARGETING
Bill Payment-Assisted Household Main Fuel

A. Unduplicated Number of LIHEAP Bill Payment-Assisted Households

All Households

Electricity

Natural Gas

Fuel Oil

Propane

Other Fuels

B. All Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)

2. Average Annual Household Income

3. Average Annual Total LIHEAP Benefit per Household (including Heating, Cooling, Crisis, Supplemental Benefits)

4. Average Annual Main Heating Fuel Bill

5. Average Annual Electricity Bill

6. Average Annual Total Residential Energy Bill

Auto-Calculated

7. Average Annual Burden Before Receiving LIHEAP

Auto-Calculated

8. Average Annual Burden After Receiving LIHEAP

Auto-Calculated

9. Average Percentage Point Change in Energy Burden

Auto-Calculated

10. Average Percentage Reduction in Energy Burden

Auto-Calculated

C. High Burden Households with 12 Consecutive Months of Bill Data (Main Fuel and Electric)
1. Unduplicated Number of High Burden Households (Top 25%) with 12 Consecutive Months of Bill Data (Main Fuel and Electric)

2. Average Annual Household Income for High Burden Households

3. Average Annual Total LIHEAP Benefit per High Burden Household (including Heating, Cooling, Crisis, Supplemental Benefits)

4. Average Annual Main Heating Fuel Bill for High Burden Households

5. Average Annual Electricity Bill for High Burden Households

6. Average Annual Total Residential Energy Bill for High Burden Households

Auto-Calculated

7. Average Annual Burden Before Receiving LIHEAP for High Burden Households

Auto-Calculated

8. Average Annual Burden After Receiving LIHEAP for High Burden Households

Auto-Calculated

9. Average Percentage Point Change in Energy Burden for High Burden Households

Auto-Calculated

10. Average Percentage Reduction in Energy Burden for High Burden Households

Auto-Calculated

D. Benefit Targeting Index for High Burden Households:

Auto-Calculated

E. Burden Reduction Targeting Index for High Burden Households:

Auto-Calculated

VI. RESTORATION OF HOME ENERGY SERVICE
Energy Source (where LIHEAP benefit was applied)

A. All Occurrences of LIHEAP Households that Had:

All Occurrences

Electricity

Natural Gas

1. Energy Service Restored After Disconnection

Auto-Calculated

2. Fuel Delivered to Home that Ran Out of Fuel

Auto-Calculated

3. Repair/Replacement of Inoperable Home Energy Equipment

Auto-Calculated

Fuel Oil

Propane

Other Fuels

VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE
Energy Source (where LIHEAP benefit was applied)

A. All Occurrences of LIHEAP Households that Had:

All Occurrences

Electricity

Natural Gas

1. Past Due Notice or Utility Disconnect Notice

Auto-Calculated

2. Imminent Risk of Running out of Fuel

Auto-Calculated

3. Repair/Replacement of Operable Equipment to Prevent Imminent Home Energy Loss

Auto-Calculated

NOTES: Include any notes.

Fuel Oil

Propane

Other Fuels