Form DOE F 540.5 DOE F 540.5 WAP Subgrantee Information Worksheet

Weather Assistance Program (WAP)

WAP Subgrantee Information Worksheet 2019 - Form

Weather Assistance Program (WAP)

OMB: 1910-5127

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DOE F 540.5 OMB Control No. 1910-5127

Expiration date: XX/XX/2023


U.S. Department of Energy

WEATHERIZATION ASSISTANCE PROGRAM

SUBGRANTEE INFORMATION


Grant #: __________ State: ___________ Program Year: __________


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Duns Number: __________________________________ Name: __________________________________________


Phone: ________________________________________ Email: __________________________________________


Address 1: ___________________________________________ Contact: ________________________________________


Address 2: ___________________________________________ Fax: ___________________________________________


City: __________________________________________________ State: ________________ Zip Code: _____________

Tentative allocation:



Counties served:


Congressional Districts:

Planned units:






Type of organization:






Sources of Labor:










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Duns Number: __________________________________ Name: __________________________________________


Phone: ________________________________________ Email: __________________________________________


Address 1: ___________________________________________ Contact: ________________________________________


Address 2: ___________________________________________ Fax: ___________________________________________


City: __________________________________________________ State: ________________ Zip Code: _____________

Tentative allocation:



Counties served:


Congressional Districts:

Planned units:






Type of organization:






Sources of Labor:










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Duns Number: __________________________________ Name: __________________________________________


Phone: ________________________________________ Email: __________________________________________


Address 1: ___________________________________________ Contact: ________________________________________


Address 2: ___________________________________________ Fax: ___________________________________________


City: __________________________________________________ State: ________________ Zip Code: _____________

Tentative allocation:



Counties served:


Congressional Districts:

Planned units:






Type of organization:






Sources of Labor:










OMB Burden Disclosure Statement


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. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.


PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.


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U.S. Department of Energy

WEATHERIZATION ASSISTANCE PROGRAM

WAP SUBGRANTEE INFORMATION

INSTRUCTIONS






Item


Explanation



DUNS Number


Enter the unique Dun & Bradstreet (DUNS) number associated with the subgrantee (Required)



Name


Name of subgrantee contracted by the state to perform weatherization services (Required)




Contact

Name of contact at the agency




Phone, Email, Address, Fax, City, State, and Zip Code


Self-explanatory (Required)




Tentative Allocation

Self-explanatory (Required). Tentative allocation can include non-DOE funding if included in the DOE budget.




Planned Units

Self-explanatory (Required). Planned units can include those completed with non-DOE funds if included in DOE budget.




Type of Organization



Sources of Labor


Local action agency, non-profit, tribal organization, unit of local government (Required)


Crews, contractors, or both (Required)



Counties Served

Self-explanatory (Required)




Congressional Districts

Self-explanatory (Required)



Complete this information for each subgrantee.


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