LIHEAP Detailed Model Plan Application

Mandatory Grant Application SF-424
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

* 1.a. Type of Submission:

* 1.b. Frequency:

* 1.c. Consolidated Application/
Plan/Funding Request?

* 1.d. Version:
Initial
Resubmission

Explanation:

Revision
Update
State Use Only:

2. Date Received:
3. Applicant Identifier:
4a. Federal Entity Identifier:

5. Date Received By State:

4b. Federal Award Identifier:

6. State Application Identifier:

7. APPLICANT INFORMATION
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN):

* c. Organizational DUNS:

* d. Address:
* Street 1:

Street 2:

* City:

County:

* State:

Province:

* Country:

* Zip / Postal
Code:

e. Organizational Unit:
Department Name:

Division Name:

f. Name and contact information of person to be contacted on matters involving this application:
Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Telephone
Number:

Fax Number

* Email:

* 8a. TYPE OF APPLICANT:
b. Additional Description:
* 9. Name of Federal Agency:

Catalog of Federal Domestic
Assistance Number:
10. CFDA Numbers and Titles

11. Descriptive Title of Applicant's Project
12. Areas Affected by Funding:
13. CONGRESSIONAL DISTRICTS OF:
* a. Applicant

b. Program/Project:

Page 2 of 49

CFDA Title:

Attach an additional list of Program/Project Congressional Districts if needed.
14. FUNDING PERIOD:
a. Start Date:

15. ESTIMATED FUNDING:
* a. Federal ($):

b. End Date:

b. Match ($):

* 16. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?
a. This submission was made available to the State under the Executive Order 12372
Process for Review on :
b. Program is subject to E.O. 12372 but has not been selected by State for review.
c. Program is not covered by E.O. 12372.
* 17. Is The Applicant Delinquent On Any Federal Debt?
YES
NO
Explanation:
18. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true,
complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I
accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative
penalties. (U.S. Code, Title 218, Section 1001)

**I Agree
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency
specific instructions.
18a. Typed or Printed Name and Title of Authorized Certifying Official

18c. Telephone (area code, number and extension)
18d. Email Address

18b. Signature of Authorized Certifying Official

18e. Date Report Submitted (Month, Day, Year)

Attach supporting documents as specified in agency instructions.

Page 3 of 49

Section 1 - Program Components
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Department of Health and Human Services
Administration for Children and Families
Office of Community Services
Washington, DC 20201
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Approval No. 0970-0075
Expiration Date: 09/30/2020
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)Use of this model plan is optional. However, the information requested is
required in order to receive a Low Income Home Energy Assistance Program (LIHEAP) grant in years in which the grantee is not permitted to
file an abbreviated plan. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the
time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.

Section 1 Program Components
Program Components, 2605(a), 2605(b)(1) - Assurance 1, 2605(c)(1)(C)
1.1 Check which components you will operate under the LIHEAP program.
(Note: You must provide information for each component designated here as requested elsewhere in
this plan.)

Dates of Operation

Start Date

End Date

Heating assistance

Cooling assistance

Crisis assistance

Weatherization assistance

Provide further explanation for the dates of operation, if necessary

Estimated Funding Allocation, 2604(C), 2605(k)(1), 2605(b)(9), 2605(b)(16) - Assurances 9 and 16
1.2 Estimate what amount of available LIHEAP funds will be used for each component that you will operate: The total of all percentages
must add up to 100%.

Percentage ( % )

Heating assistance

0.00%

Cooling assistance

0.00%

Crisis assistance

0.00%

Weatherization assistance

0.00%

Carryover to the following federal fiscal year

0.00%

Administrative and planning costs

0.00%

Services to reduce home energy needs including needs assessment (Assurance 16)

0.00%

Page 4 of 49

0.00%

Used to develop and implement leveraging activities
TOTAL

0.00%

Alternate Use of Crisis Assistance Funds, 2605(c)(1)(C)
1.3 The funds reserved for winter crisis assistance that have not been expended by March 15 will be reprogrammed to:
Heating assistance

Cooling assistance

Weatherization assistance

Other (specify:)

Categorical Eligibility, 2605(b)(2)(A) - Assurance 2, 2605(c)(1)(A), 2605(b)(8A) - Assurance 8
1.4 Do you consider households categorically eligible if one household member receives one of the following categories of benefits in the left
column below?

Yes

No

If you answered "Yes" to question 1.4, you must complete the table below and answer questions 1.5 and 1.6.
Heating

Cooling

Crisis

Weatherization

TANF

Yes

No

Yes

No

Yes

No

Yes

No

SSI

Yes

No

Yes

No

Yes

No

Yes

No

SNAP

Yes

No

Yes

No

Yes

No

Yes

No

Means-tested Veterans Programs

Yes

No

Yes

No

Yes

No

Yes

No

Program Name
Other(Specify) 1

Heating

Yes

No

1.5 Do you automatically enroll households without a direct annual application?

Cooling

Yes

No

Yes

No

Crisis

Yes

No

Weatherization

Yes

No

If Yes, explain:

1.6 How do you ensure there is no difference in the treatment of categorically eligible households from those not receiving other public assistance
when determining eligibility and benefit amounts?

SNAP Nominal Payments
1.7a Do you allocate LIHEAP funds toward a nominal payment for SNAP households?

Yes

No

If you answered "Yes" to question 1.7a, you must provide a response to questions 1.7b, 1.7c, and 1.7d.
1.7b Amount of Nominal Assistance: $0.00
1.7c Frequency of Assistance
Once Per Year

Once every five years

Other - Describe:

1.7d How do you confirm that the household receiving a nominal payment has an energy cost or need?

Determination of Eligibility - Countable Income
1.8. In determining a household's income eligibility for LIHEAP, do you use gross income or net income ?
Gross Income

Net Income

1.9. Select all the applicable forms of countable income used to determine a household's income eligibility for LIHEAP
Wages

Self - Employment Income

Contract Income

Page 5 of 49

Payments from mortgage or Sales Contracts

Unemployment insurance

Strike Pay

Social Security Administration (SSA ) benefits

Including MediCare
deduction

Excluding MediCare deduction

Supplemental Security Income (SSI )

Retirement / pension benefits

General Assistance benefits

Temporary Assistance for Needy Families (TANF) benefits

Supplemental Nutrition Assistance Program (SNAP) benefits

Women, Infants, and Children Supplemental Nutrition Program (WIC) benefits

Loans that need to be repaid

Cash gifts

Savings account balance

One-time lump-sum payments, such as rebates/credits, winnings from lotteries, refund deposits, etc.

Jury duty compensation

Rental income

Income from employment through Workforce Investment Act (WIA)

Income from work study programs

Alimony

Child support

Interest, dividends, or royalties

Commissions

Legal settlements

Insurance payments made directly to the insured

Insurance payments made specifically for the repayment of a bill, debt, or estimate

Veterans Administration (VA) benefits

Page 6 of 49

Earned income of a child under the age of 18

Balance of retirement, pension, or annuity accounts where funds cannot be withdrawn without a penalty.

Income tax refunds

Stipends from senior companion programs, such as VISTA

Funds received by household for the care of a foster child

Ameri-Corp Program payments for living allowances, earnings, and in-kind aid

Reimbursements (for mileage, gas, lodging, meals, etc.)

Other

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 7 of 49

Section 2 - HEATING ASSISTANCE
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 2 - Heating Assistance
Eligibility, 2605(b)(2) - Assurance 2
2.1 Designate the income eligibility threshold used for the heating component:
Add

Household size

Eligibility Guideline

Eligibility Threshold

0.00%

1

2.2 Do you have additional eligibility requirements for
HEATING ASSITANCE?

Yes

No

2.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test ?

Yes

No

Renters?

Yes

No

Renters Living in subsidized housing ?

Yes

No

Renters with utilities included in the rent ?

Yes

No

Elderly?

Yes

No

Disabled?

Yes

No

Young children?

Yes

No

Households with high energy burdens ?

Yes

No

Other?

Yes

No

Do you have additional/differing eligibility policies for:

Do you give priority in eligibility to:

Explanations of policies for each "yes" checked above:

Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
2.4 Describe how you prioritize the provision of heating assistance tovulnerable populations,e.g., benefit amounts, early application periods, etc.
2.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Individual bill
Dwelling type
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:

Page 8 of 49

Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
2.6 Describe estimated benefit levels for FY 2020:
Minimum Benefit

$0

Maximum Benefit

2.7 Do you provide in-kind (e.g., blankets, space heaters) and/or other forms of benefits?

Yes

$0

No

If yes, describe.

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 9 of 49

Section 3 - COOLING ASSISTANCE
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 3 - Cooling Assistance
Eligibility, 2605(c)(1)(A), 2605 (b)(2) - Assurance 2
3.1 Designate The income eligibility threshold used for the Cooling component:
Add

Household size

Eligibility Guideline

Eligibility Threshold

0.00%

1

3.2 Do you have additional eligibility requirements for
COOLING ASSITANCE?

Yes

No

3.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test ?

Yes

No

Renters?

Yes

No

Renters Living in subsidized housing ?

Yes

No

Renters with utilities included in the rent ?

Yes

No

Elderly?

Yes

No

Disabled?

Yes

No

Young children?

Yes

No

Households with high energy burdens ?

Yes

No

Other?

Yes

No

Do you have additional/differing eligibility policies for:

Do you give priority in eligibility to:

Explanations of policies for each "yes" checked above:

3.4 Describe how you prioritize the provision of cooling assistance tovulnerable populations,e.g., benefit amounts, early application periods, etc.

Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
3.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Individual bill
Dwelling type
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:

Page 10 of 49

Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
3.6 Describe estimated benefit levels for FY 2020:
Minimum Benefit

$0

Maximum Benefit

3.7 Do you provide in-kind (e.g., fans, air conditioners) and/or other forms of benefits?

Yes

$0

No

If yes, describe.

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 11 of 49

Section 4 - CRISIS ASSISTANCE
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 4: CRISIS ASSISTANCE
Eligibility - 2604(c), 2605(c)(1)(A)
4.1 Designate the income eligibility threshold used for the crisis component
Add

Household size

Eligibility Guideline

Eligibility Threshold

0.00%

1

4.2 Provide your LIHEAP program's definition for determining a crisis.

4.3 What constitutes a life-threatening crisis?

Crisis Requirement, 2604(c)
4.4 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? Hours
4.5 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening
situations? Hours

Crisis Eligibility, 2605(c)(1)(A)
4.6 Do you have additional eligibility requirements for CRISIS
ASSISTANCE?

Yes

No

Yes

No

Elderly?

Yes

No

Disabled?

Yes

No

Young Children?

Yes

No

Households with high energy burdens?

Yes

No

Other?

Yes

No

Yes

No

Must the household have been shut off or have an empty tank?

Yes

No

Must the household have exhausted their regular heating benefit?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

4.7 Check the appropriate boxes below and describe the policies for each
Do you require an Assets test ?
Do you give priority in eligibility to :

In Order to receive crisis assistance:
Must the household have received a shut-off notice or have a near
empty tank?

Must renters with heating costs included in their rent have
received an eviction notice ?
Must heating/cooling be medically necessary?
Must the household have non-working heating or cooling
equipment?
Other?
Do you have additional / differing eligibility policies for:

Page 12 of 49

Renters?

Yes

No

Renters living in subsidized housing?

Yes

No

Renters with utilities included in the rent?

Yes

No

Explanations of policies for each "yes" checked above:

Determination of Benefits
4.8 How do you handle crisis situations?
Separate component
Fast Track
Other - Describe:
4.9 If you have a separate component, how do you determine crisis assistance benefits?
Amount to resolve the crisis.
Other - Describe:

Crisis Requirements, 2604(c)
4.10 Do you accept applications for energy crisis assistance at sites that are geographically accessible to all households in the area to be served?
Yes

No

Explain.

4.11 Do you provide individuals who are physically disabled the means to:
Submit applications for crisis benefits without leaving their homes?
Yes

No

If No, explain.

Travel to the sites at which applications for crisis assistance are accepted?
Yes

No

If No, explain.

If you answered "No" to both options in question 4.11, please explain alternative means of intake to those who are homebound or physically
disabled?

Benefit Levels, 2605(c)(1)(B)
4.12 Indicate the maximum benefit for each type of crisis assistance offered.
Winter Crisis

$0.00 maximum benefit

Summer Crisis

$0.00 maximum benefit

Year-round Crisis

$0.00 maximum benefit

4.13 Do you provide in-kind (e.g. blankets, space heaters, fans) and/or other forms of benefits?
Yes

No

If yes, Describe

4.14 Do you provide for equipment repair or replacement using crisis funds?
Yes

No

If you answered "Yes" to question 4.14, you must complete question 4.15.
4.15 Check appropriate boxes below to indicate type(s) of assistance provided.
Winter
Crisis

Summer
Crisis

Year-round Crisis

Heating system repair

Heating system replacement

Cooling system repair

Cooling system replacement

Page 13 of 49

Wood stove purchase

Pellet stove purchase

Solar panel(s)

Utility poles / gas line hook-ups

Other (Specify):

4.16 Do any of the utility vendors you work with enforce a moratorium on shut offs?
Yes

No

If you responded "Yes" to question 4.16, you must respond to question 4.17.
4.17 Describe the terms of the moratorium and any special dispensation received by LIHEAP clients during or after the moratorium period.

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 14 of 49

Section 5 - WEATHERIZATION ASSISTANCE
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 5: WEATHERIZATION ASSISTANCE
Eligibility, 2605(c)(1)(A), 2605(b)(2) - Assurance 2
5.1 Designate the income eligibility threshold used for the Weatherization component
Add

Household Size

Eligibility Guideline

Eligibility Threshold

0.00%

1

5.2 Do you enter into an interagency agreement to have another government agency administer a WEATHERIZATION component?
No

Yes

5.3 If yes, name the agency.
5.4 Is there a separate monitoring protocol for weatherization?

Yes

No

WEATHERIZATION - Types of Rules
5.5 Under what rules do you administer LIHEAP weatherization? (Check only one.)
Entirely under LIHEAP (not DOE) rules
Entirely under DOE WAP (not LIHEAP) rules
Mostly under LIHEAP rules with the following DOE WAP rule(s) where LIHEAP and WAP rules differ (Check all that apply):
Income Threshold
Weatherization of entire multi-family housing structure is permitted if at least 66% of units (50% in 2- & 4-unit buildings) are
eligible units or will become eligible within 180 days
Weatherize shelters temporarily housing primarily low income persons (excluding nursing homes, prisons, and similar institutional
care facilities).
Other - Describe:

Mostly under DOE WAP rules, with the following LIHEAP rule(s) where LIHEAP and WAP rules differ (Check all that apply.)
Income Threshold
Weatherization not subject to DOE WAP maximum statewide average cost per dwelling unit.
Weatherization measures are not subject to DOE Savings to Investment Ration (SIR ) standards.
Other - Describe:

Eligibility, 2605(b)(5) - Assurance 5
5.6 Do you require an assets test?

Yes

No

5.7 Do you have additional/differing eligibility policies for :
Renters

Yes

No

Yes

No

Elderly?

Yes

No

Disabled?

Yes

No

Renters living in subsidized
housing?
5.8 Do you give priority in eligibility to:

Page 15 of 49

Young Children?
House holds with high energy
burdens?
Other?

Yes

No

Yes

No

Yes

No

If you selected "Yes" for any of the options in questions 5.6, 5.7, or 5.8, you must provide further explanation of these policies in the text field
below.

Benefit Levels
5.9 Do you have a maximum LIHEAP weatherization benefit/expenditure per household?

Yes

No

5.10 If yes, what is the maximum? $0

Types of Assistance, 2605(c)(1), (B) & (D)
5.11 What LIHEAP weatherization measures do you provide ? (Check all categories that apply.)
Weatherization needs assessments/audits

Energy related roof repair

Caulking and insulation

Major appliance Repairs

Storm windows

Major appliance replacement

Furnace/heating system modifications/ repairs

Windows/sliding glass doors

Furnace replacement

Doors

Cooling system modifications/ repairs

Water Heater

Water conservation measures

Cooling system replacement

Compact florescent light bulbs

Other - Describe:

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 16 of 49

Section 6 - Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 6: Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A)
6.1 Select all outreach activities that you conduct that are designed to assure that eligible households are made aware of all LIHEAP assistance
available:

Place posters/flyers in local and county social service offices, offices of aging, Social Security offices, VA, etc.

Publish articles in local newspapers or broadcast media announcements.

Include inserts in energy vendor billings to inform individuals of the availability of all types of LIHEAP assistance.

Mass mailing(s) to prior-year LIHEAP recipients.

Inform low income applicants of the availability of all types of LIHEAP assistance at application intake for other lowincome programs.

Execute interagency agreements with other low-income program offices to perform outreach to target groups.

Other (specify):

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 17 of 49

Section 7 - Coordination, 2605(b)(4) - Assurance 4
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 7: Coordination, 2605(b)(4) - Assurance 4
7.1 Describe how you will ensure that the LIHEAP program is coordinated with other programs available to low-income households (TANF,
SSI, WAP, etc.).
Joint application for multiple programs

Intake referrals to/from other programs

One - stop intake centers

Other - Describe:

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 18 of 49

Section 8 - Agency Designation,, 2605(b)(6) - Assurance 6
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 8: Agency Designation, 2605(b)(6) - Assurance 6 (Required for state grantees and
the Commonwealth of Puerto Rico)
8.1 How would you categorize the primary responsibility of your State agency?
Administration Agency

Commerce Agency

Community Services Agency

Energy / Environment Agency

Housing Agency

Welfare Agency

Other - Describe:

Alternate Outreach and Intake, 2605(b)(15) - Assurance 15
If you selected "Welfare Agency" in question 8.1, you must complete questions 8.2, 8.3, and 8.4, as applicable.
8.2 How do you provide alternate outreach and intake for HEATING ASSISTANCE?

8.3 How do you provide alternate outreach and intake for COOLING ASSISTANCE?

8.4 How do you provide alternate outreach and intake for CRISIS ASSISTANCE?

8.5 LIHEAP Component Administration.

Heating

Cooling

8.5a Who determines client eligibility?
8.5b Who processes benefit payments to gas and
electric vendors?
8.5c who processes benefit payments to bulk fuel
vendors?
8.5d Who performs installation of weatherization
measures?

Page 19 of 49

Crisis

Weatherization

If any of your LIHEAP components are not centrally-administered by a state agency, you must
complete questions 8.6, 8.7, 8.8, and, if applicable, 8.9.

8.6 What is your process for selecting local administering agencies?

8.7 How many local administering agencies do you use?
8.8 Have you changed any local administering agencies in the last year?
Yes
No

8.9 If so, why?
Agency was in noncompliance with grantee requirements for LIHEAP -

Agency is under criminal investigation

Added agency

Agency closed

Other - describe

If any of the above questions require further explanation or clarification that could not be made
in the fields provided, attach a document with said explanation here.

Page 20 of 49

Section 9 - Energy Suppliers,, 2605(b)(7) - Assurance 7
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 9: Energy Suppliers, 2605(b)(7) - Assurance 7
9.1 Do you make payments directly to home energy suppliers?
Heating

Yes

No

Cooling

Yes

No

Crisis

Yes

No

Are there exceptions?

Yes

No

If yes, Describe.

9.2 How do you notify the client of the amount of assistance paid?

9.3 How do you assure that the home energy supplier will charge the eligible household, in the normal billing process, the difference between the
actual cost of the home energy and the amount of the payment?

9.4 How do you assure that no household receiving assistance under this title will be treated adversely because of their receipt of LIHEAP
assistance?

9.5. Do you make payments contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible
households?
Yes

No

If so, describe the measures unregulated vendors may take.

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 21 of 49

Section 10 - Program, Fiscal Monitoring, and Audit, 2605(b)(10) - Assurance 10
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 10: Program, Fiscal Monitoring, and Audit, 2605(b)(10)
10.1. How do you ensure good fiscal accounting and tracking of LIHEAP funds?

Audit Process
10.2. Is your LIHEAP program audited annually under the Single Audit Act and OMB Circular A - 133?
Yes

No

10.3. Describe any audit findings rising to the level of material weakness or reportable condition cited in the A-133 audits, Grantee monitoring
assessments, inspector general reviews, or other government agency reviews of the LIHEAP agency from the most recently audited fiscal year.

No Findings
Finding

Type

Brief Summary

Resolved?

Action Taken

1

10.4. Audits of Local Administering Agencies
What types of annual audit requirements do you have in place for local administering agencies/district offices?
Select all that apply.
Local agencies/district offices are required to have an annual audit in compliance with Single Audit Act and OMB Circular A-133
Local agencies/district offices are required to have an annual audit (other than A-133)
Local agencies/district offices' A-133 or other independent audits are reviewed by Grantee as part of compliance process.
Grantee conducts fiscal and program monitoring of local agencies/district offices
Compliance Monitoring
10.5. Describe the Grantee's strategies for monitoring compliance with the Grantee's and Federal LIHEAP policies and procedures: Select all
that apply
Grantee employees:
Internal program review
Departmental oversight
Secondary review of invoices and payments
Other program review mechanisms are in place. Describe:

Local Administering Agencies / District Offices:
On - site evaluation
Annual program review
Monitoring through central database

Page 22 of 49

Desk reviews
Client File Testing / Sampling
Other program review mechanisms are in place. Describe:

10.6 Explain, or attach a copy of your local agency monitoring schedule and protocol.

10.7. Describe how you select local agencies for monitoring reviews.
Site Visits:
Desk Reviews:
10.8. How often is each local agency monitored ?

10.9. What is the combined error rate for eligibility determinations? OPTIONAL

10.10. What is the combined error rate for benefit determinations? OPTIONAL
10.11. How many local agencies are currently on corrective action plans for eligibility and/or benefit determination issues?
10.12. How many local agencies are currently on corrective action plans for financial accounting or administrative issues?

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 23 of 49

Section 11 - Timely and Meaningful Public Participation, , 2605(b)(12) - Assurance 12, 2605(c)(2)
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 11: Timely and Meaningful Public Participation, 2605(b)(12), 2605(C)(2)
11.1 How did you obtain input from the public in the development of your LIHEAP plan?
Select all that apply.
Tribal Council meeting(s)
Public Hearing(s)
Draft Plan posted to website and available for comment
Hard copy of plan is available for public view and comment
Comments from applicants are recorded
Request for comments on draft Plan is advertised
Stakeholder consultation meeting(s)
Comments are solicited during outreach activities
Other - Describe:
11.2 What changes did you make to your LIHEAP plan as a result of this participation?

Public Hearings, 2605(a)(2) - For States and the Commonwealth of Puerto Rico Only
11.3 List the date and location(s) that you held public hearing(s) on the proposed use and distribution of your LIHEAP funds?
Date

Event Description

1

11.4. How many parties commented on your plan at the hearing(s)?
11.5 Summarize the comments you received at the hearing(s).
11.6 What changes did you make to your LIHEAP plan as a result of the comments received at the public hearing(s)?

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 24 of 49

Section 12 - Fair Hearings,2605(b)(13) - Assurance 13
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 12: Fair Hearings, 2605(b)(13) - Assurance 13
12.1 How many fair hearings did the grantee have in the prior Federal fiscal year?
12.2 How many of those fair hearings resulted in the initial decision being reversed?
12.3 Describe any policy and/or procedural changes made in the last Federal fiscal year as a result of fair hearings?

12.4 Describe your fair hearing procedures for households whose applications are denied.

12.5 When and how are applicants informed of these rights?

12.6 Describe your fair hearing procedures for households whose applications are not acted on in a timely manner.

12.7 When and how are applicants informed of these rights?

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 25 of 49

Section 13 - Reduction of home energy needs,2605(b)(16) - Assurance 16
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 13: Reduction of home energy needs, 2605(b)(16) - Assurance 16
13.1 Describe how you use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and
thereby the need for energy assistance?

13.2 How do you ensure that you don't use more than 5% of your LIHEAP funds for these activities?

13.3 Describe the impact of such activities on the number of households served in the previous Federal fiscal year.

13.4 Describe the level ofdirect benefitsprovided to those households in the previous Federal fiscal year.

13.5 How many households applied for these services?
13.6 How many households received these services?

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 26 of 49

Section 14 - Leveraging Incentive Program ,2607A
August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 14:Leveraging Incentive Program, 2607(A)
14.1 Do you plan to submit an application for the leveraging incentive program?
Yes

No

14.2 Describe instructions to any third parties and/or local agencies for submitting LIHEAP leveraging resource information and retaining
records.

14.3 For each type of resource and/or benefit to be leveraged in the upcoming year that will meet the requirements of45 C.F.R. § 96.87(d)(2)(iii),
describe the following:
Resource

What is the type of
resource or benefit ?

What is the source(s) of the
resource ?

How will the resource be integrated and coordinated with LIHEAP?

1

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 27 of 49

Section 15 - Training
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 15: Training
15.1 Describe the training you provide for each of the following groups:
a. Grantee Staff:
Formal training on grantee policies and procedures
How often?
Annually
Biannually
As needed
Other - Describe:
Employees are provided with policy manual
Other-Describe:
b. Local Agencies:
Formal training conference
How often?
Annually
Biannually
As needed
Other - Describe:
On-site training
How often?
Annually
Biannually
As needed
Other - Describe:
Employees are provided with policy manual
Other - Describe
c. Vendors
Formal training conference
How often?
Annually
Biannually
As needed

Page 28 of 49

Other - Describe:
Policies communicated through vendor agreements
Policies are outlined in a vendor manual
Other - Describe:

15.2 Does your training program address fraud reporting and prevention?
Yes
No

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 29 of 49

Section 16 - Performance Goals and Measures, 2605(b)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 16: Performance Goals and Measures, 2605(b) - Required for States Only
16.1 Describe your progress toward meeting the data collection and reporting requirements of the four required LIHEAP performance
measures. Include timeframes and plans for meeting these requirements and what you believe will be accomplished in the coming federal fiscal
year.

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 30 of 49

Section 17 - Program Integrity, 2605(b)(10)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

August 1987, revised 05/92,02/95,03/96,12/98,11/01
OMB Clearance No.: 0970-0075
Expiration Date: XX/XX/XXXX

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY

Section 17: Program Integrity, 2605(b)(10)
17.1 Fraud Reporting Mechanisms
a. Describe all mechanisms available to the public for reporting cases of suspected waste, fraud, and abuse. Select all that apply.
Online Fraud Reporting
Dedicated Fraud Reporting Hotline
Report directly to local agency/district office or Grantee office
Report to State Inspector General or Attorney General
Forms and procedures in place for local agencies/district offices and vendors to report fraud, waste, and abuse
Other - Describe:
b. Describe strategies in place for advertising the above-referenced resources. Select all that apply
Printed outreach materials
Addressed on LIHEAP application
Website
Other - Describe:

17.2. Identification Documentation Requirements
a. Indicate which of the following forms of identification are required or requested to be collected from LIHEAP applicants or their household
members.

Collected from Whom?
Type of Identification Collected
Applicant Only

All Adults in Household

All Household Members

Required

Required

Required

Requested

Requested

Requested

Required

Required

Required

Requested

Requested

Requested

Required

Required

Required

Requested

Requested

Requested

Social Security Card is
photocopied and retained

Social Security Number (Without
actual Card)

Government-issued identification
card
(i.e.: driver's license, state ID,
Tribal ID, passport, etc.)

Page 31 of 49

Other

Applicant Only
Required

Applicant Only
Requested

All Adults in
Household
Required

All Adults in
Household
Requested

All Household
Members
Required

All Household
Members
Requested

1

b. Describe any exceptions to the above policies.
17.3 Identification Verification
Describe what methods are used to verify the authenticity of identification documents provided by clients or household members. Select all that
apply
Verify SSNs with Social Security Administration
Match SSNs with death records from Social Security Administration or state agency
Match SSNs with state eligibility/case management system (e.g., SNAP, TANF)
Match with state Department of Labor system
Match with state and/or federal corrections system
Match with state child support system
Verification using private software (e.g., The Work Number)
In-person certification by staff (for tribal grantees only)
Match SSN/Tribal ID number with tribal database or enrollment records (for tribal grantees only)
Other - Describe:

17.4. Citizenship/Legal Residency Verification
What are your procedures for ensuring that household members are U.S. citizens or aliens who are qualified to receive LIHEAP benefits? Select
all that apply.
Clients sign an attestation of citizenship or legal residency
Client's submission of Social Security cards is accepted as proof of legal residency
Noncitizens must provide documentation of immigration status
Citizens must provide a copy of their birth certificate, naturalization papers, or passport
Noncitizens are verified through the SAVE system
Tribal members are verified through Tribal enrollment records/Tribal ID card
Other - Describe:

17.5. Income Verification
What methods does your agency utilize to verify household income? Select all that apply.
Require documentation of income for all adult household members
Pay stubs
Social Security award letters
Bank statements
Tax statements
Zero-income statements
Unemployment Insurance letters
Other - Describe:

Computer data matches:
Income information matched against state computer system (e.g., SNAP, TANF)
Proof of unemployment benefits verified with state Department of Labor

Page 32 of 49

Social Security income verified with SSA
Utilize state directory of new hires
Other - Describe:

17.6. Protection of Privacy and Confidentiality
Describe the financial and operating controls in place to protect client information against improper use or disclosure. Select all that apply.
Policy in place prohibiting release of information without written consent
Grantee LIHEAP database includes privacy/confidentiality safeguards
Employee training on confidentiality for:
Grantee employees
Local agencies/district offices
Employees must sign confidentiality agreement
Grantee employees
Local agencies/district offices
Physical files are stored in a secure location
Other - Describe:

17.7. Verifying the Authenticity
What policies are in place for verifying vendor authenticity? Select all that apply.
All vendors must register with the State/Tribe.
All vendors must supply a valid SSN or TIN/W-9 form
Vendors are verified through energy bills provided by the household
Grantee and/or local agencies/district offices perform physical monitoring of vendors
Other - Describe and note any exceptions to policies above:

17.8. Benefits Policy - Gas and Electric Utilities
What policies are in place to protect against fraud when making benefit payments to gas and electric utilities on behalf of clients? Select all that
apply.
Applicants required to submit proof of physical residency
Applicants must submit current utility bill
Data exchange with utilities that verifies:
Account ownership
Consumption
Balances
Payment history
Account is properly credited with benefit
Other - Describe:

Centralized computer system/database tracks payments to all utilities
Centralized computer system automatically generates benefit level
Separation of duties between intake and payment approval
Payments coordinated among other energy assistance programs to avoid duplication of payments
Payments to utilities and invoices from utilities are reviewed for accuracy
Computer databases are periodically reviewed to verify accuracy and timeliness of payments made to utilities
Direct payment to households are made in limited cases only
Procedures are in place to require prompt refunds from utilities in cases of account closure

Page 33 of 49

Vendor agreements specify requirements selected above, and provide enforcement mechanism
Other - Describe:

17.9. Benefits Policy - Bulk Fuel Vendors
What procedures are in place for averting fraud and improper payments when dealing with bulk fuel suppliers of heating oil, propane, wood,
and other bulk fuel vendors? Select all that apply.
Vendors are checked against an approved vendors list
Centralized computer system/database is used to track payments to all vendors
Clients are relied on for reports of non-delivery or partial delivery
Two-party checks are issued naming client and vendor
Direct payment to households are made in limited cases only
Vendors are only paid once they provide a delivery receipt signed by the client
Conduct monitoring of bulk fuel vendors
Bulk fuel vendors are required to submit reports to the Grantee
Vendor agreements specify requirements selected above, and provide enforcement mechanism
Other - Describe:
17.10. Investigations and Prosecutions
Describe the Grantee's procedures for investigating and prosecuting reports of fraud, and any sanctions placed on clients/staff/vendors found to
have committed fraud. Select all that apply.
Refer to state Inspector General
Refer to local prosecutor or state Attorney General
Refer to US DHHS Inspector General (including referral to OIG hotline)
Local agencies/district offices or Grantee conduct investigation of fraud complaints from public
Grantee attempts collection of improper payments. If so, describe the recoupment process

Clients found to have committed fraud are banned from LIHEAP assistance. For how long is a household banned?
Contracts with local agencies require that employees found to have committed fraud are reprimanded and/or terminated
Vendors found to have committed fraud may no longer participate in LIHEAP
Other - Describe:

If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.

Page 34 of 49

Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters

Section 18: Certification Regarding Debarment, Suspension, and Other
Responsibility Matters

Certification Regarding Debarment, Suspension, and Other Responsibility
Matters--Primary Covered Transactions
Instructions for Certification
1. By signing and submitting this proposal, the prospective primary participant
is providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The
prospective participant shall submit an explanation of why it cannot provide the
certification set out below. The certification or explanation will be considered in
connection with the department or agency's determination whether to enter into
this transaction. However, failure of the prospective primary participant to furnish a
certification or an explanation shall disqualify such person from participation in
this transaction.
3. The certification in this clause is a material representation of fact upon
which reliance was placed when the department or agency determined to enter into
this transaction. If it is later determined that the prospective primary participant
knowingly rendered an erroneous certification, in addition to other remedies
available to the Federal Government, the department or agency may terminate this
transaction for cause or default.BrBbr.
4. The prospective primary participant shall provide immediate written notice
to the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, lower tier
covered transaction, participant, person, primary covered transaction, principal,
proposal, and voluntarily excluded, as used in this clause, have the meanings set
out in the Definitions and Coverage sections of the rules implementing Executive
Order 12549. You may contact the department or agency to which this proposal is
being submitted for assistance in obtaining a copy of those regulations.
6. The prospective primary participant agrees by submitting this proposal that,
should the proposed covered transaction be entered into, it shall not knowingly
enter into any lower tier covered transaction with a person who is proposed for
debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared
ineligible, or voluntarily excluded from participation in this covered transaction,
unless authorized by the department or agency entering into this transaction.
7. The prospective primary participant further agrees by submitting this
proposal that it will include the clause titled ``Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,''

Page 35 of 49

provided by the department or agency entering into this covered transaction,
without modification, in all lower tier covered transactions and in all solicitations
for lower tier covered transactions.
8. A participant in a covered transaction may rely upon a certification of a
prospective participant in a lower tier covered transaction that it is not proposed
for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or
voluntarily excluded from the covered transaction, unless it knows that the
certification is erroneous. A participant may decide the method and frequency by
which it determines the eligibility of its principals. Each participant may, but is not
required to, check the List of Parties Excluded from Federal Procurement and
Nonprocurement Programs.
9. Nothing contained in the foregoing shall be construed to require
establishment of a system of records in order to render in good faith the
certification required by this clause. The knowledge and information of a
participant is not required to exceed that which is normally possessed by a prudent
person in the ordinary course of business dealings.
10. Except for transactions authorized under paragraph 6 of these instructions,
if a participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is proposed for debarment under 48 CFR part 9,
subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.

Certification Regarding Debarment, Suspension, and Other Responsibility
Matters--Primary Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge
and belief, that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing a
public (Federal, State or local) transaction or contract under a public transaction;
violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State or local) with commission of any of the
offenses enumerated in paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this application/proposal had
one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an

Page 36 of 49

explanation to this proposal.

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion--Lower Tier Covered Transactions
Instructions for Certification
1. By signing and submitting this proposal, the prospective lower tier
participant is providing the certification set out below.
2. The certification in this clause is a material representation of fact upon
which reliance was placed when this transaction was entered into. If it is later
determined that the prospective lower tier participant knowingly rendered an
erroneous certification, in addition to other remedies available to the Federal
Government the department or agency with which this transaction originated may
pursue available remedies, including suspension and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice
to the person to which this proposal is submitted if at any time the prospective
lower tier participant learns that its certification was erroneous when submitted or
had become erroneous by reason of changed circumstances.
4. The terms covered transaction, debarred, suspended, ineligible, lower tier
covered transaction, participant, person, primary covered transaction, principal,
proposal, and voluntarily excluded, as used in this clause, have the meaning set
out in the Definitions and Coverage sections of rules implementing Executive Order
12549. You may contact the person to which this proposal is submitted for
assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal
that, [[Page 33043]] should the proposed covered transaction be entered into, it
shall not knowingly enter into any lower tier covered transaction with a person who
is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended,
declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency with which this
transaction originated.
6. The prospective lower tier participant further agrees by submitting this
proposal that it will include this clause titled ``Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,''
without modification, in all lower tier covered transactions and in all solicitations
for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a
prospective participant in a lower tier covered transaction that it is not proposed
for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or
voluntarily excluded from covered transactions, unless it knows that the
certification is erroneous. A participant may decide the method and frequency by
which it determines the eligibility of its principals. Each participant may, but is not
required to, check the List of Parties Excluded from Federal Procurement and
Nonprocurement Programs.
8. Nothing contained in the foregoing shall be construed to require

Page 37 of 49

establishment of a system of records in order to render in good faith the
certification required by this clause. The knowledge and information of a
participant is not required to exceed that which is normally possessed by a prudent
person in the ordinary course of business dealings.
9. Except for transactions authorized under paragraph 5 of these instructions,
if a participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is proposed for debarment under 48 CFR part 9,
subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to the
Federal Government, the department or agency with which this transaction
originated may pursue available remedies, including suspension and/or debarment.

Certification Regarding Debarment, Suspension, Ineligibility an Voluntary
Exclusion--Lower Tier Covered Transactions
(1) The prospective lower tier participant certifies, by submission of this
proposal, that neither it nor its principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an
explanation to this proposal.

By checking this box, the prospective primary participant is providing the
certification set out above.

Page 38 of 49

Section 19: Certification Regarding Drug-Free Workplace Requirements

Section 19: Certification Regarding Drug-Free Workplace Requirements
This certification is required by the regulations implementing the Drug-Free
Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2)
and 76.645(a)(1) and (b) provide that a Federal agency may designate a central
receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for
notification of criminal drug convictions. For the Department of Health and
Human Services, the central pint is: Division of Grants Management and
Oversight, Office of Management and Acquisition, Department of Health and
Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC
20201.
Certification Regarding Drug-Free Workplace Requirements (Instructions for
Certification)
1. By signing and/or submitting this application or grant agreement, the grantee
is providing the certification set out below.
2. The certification set out below is a material representation of fact upon which
reliance is placed when the agency awards the grant. If it is later determined that
the grantee knowingly rendered a false certification, or otherwise violates the
requirements of the Drug-Free Workplace Act, the agency, in addition to any
other remedies available to the Federal Government, may take action authorized
under the Drug-Free Workplace Act.
3. For grantees other than individuals, Alternate I applies.
4. For grantees who are individuals, Alternate II applies.
5. Workplaces under grants, for grantees other than individuals, need not be
identified on the certification. If known, they may be identified in the grant
application. If the grantee does not identify the workplaces at the time of
application, or upon award, if there is no application, the grantee must keep the
identity of the workplace(s) on file in its office and make the information
available for Federal inspection. Failure to identify all known workplaces
constitutes a violation of the grantee's drug-free workplace requirements.
6. Workplace identifications must include the actual address of buildings (or
parts of buildings) or other sites where work under the grant takes place.
Categorical descriptions may be used (e.g., all vehicles of a mass transit
authority or State highway department while in operation, State employees in
each local unemployment office, performers in concert halls or radio studios).
7. If the workplace identified to the agency changes during the performance of
Page 39 of 49

the grant, the grantee shall inform the agency of the change(s), if it previously
identified the workplaces in question (see paragraph five).
8. Definitions of terms in the Nonprocurement Suspension and Debarment
common rule and Drug-Free Workplace common rule apply to this certification.
Grantees' attention is called, in particular, to the following definitions from these
rules:
Controlled substance means a controlled substance in Schedules I through V of
the Controlled Substances Act (21 U.S.C. 812) and as further defined by
regulation (21 CFR 1308.11 through 1308.15);
Conviction means a finding of guilt (including a plea of nolo contendere) or
imposition of sentence, or both, by any judicial body charged with the
responsibility to determine violations of the Federal or State criminal drug
statutes;
Criminal drug statute means a Federal or non-Federal criminal statute involving
the manufacture, distribution, dispensing, use, or possession of any controlled
substance;
Employee means the employee of a grantee directly engaged in the performance
of work under a grant, including: (i) All direct charge employees; (ii) All indirect
charge employees unless their impact or involvement is insignificant to the
performance of the grant; and, (iii) Temporary personnel and consultants who
are directly engaged in the performance of work under the grant and who are on
the grantee's payroll. This definition does not include workers not on the payroll
of the grantee (e.g., volunteers, even if used to meet a matching requirement;
consultants or independent contractors not on the grantee's payroll; or
employees of subrecipients or subcontractors in covered workplaces).

Certification Regarding Drug-Free Workplace Requirements
Alternate I. (Grantees Other Than Individuals)
The grantee certifies that it will or will continue to provide a drug-free workplace
by:,
(a) Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance is prohibited
in the grantee's workplace and specifying the actions that will be taken against
employees for violation of such prohibition;
(b) Establishing an ongoing drug-free awareness program to inform employees
about -(1)The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance

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programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
c) Making it a requirement that each employee to be engaged in the performance of
the grant be given a copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a
condition of employment under the grant, the employee will -(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a
criminal drug statute occurring in the workplace no later than five calendar days
after such conviction;
(e) Notifying the agency in writing, within ten calendar days after receiving notice
under paragraph (d)(2) from an employee or otherwise receiving actual notice of
such conviction. Employers of convicted employees must provide notice, including
position title, to every grant officer or other designee on whose grant activity the
convicted employee was working, unless the Federal agency has designated a
central point for the receipt of such notices. Notice shall include the identification
number(s) of each affected grant;
(f)Taking one of the following actions, within 30 calendar days of receiving notice
under paragraph (d)(2), with respect to any employee who is so convicted -(1)
Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance
or rehabilitation program approved for such purposes by a Federal, State, or local
health, law enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e) and (f).
(B) The grantee may insert in the space provided below the site(s) for the
performance of work done in connection with the specific grant:

Place of Performance (Street address, city, county, state, zip code)

* Address Line 1

Address Line 2

Address Line 3

* City

* State

* Zip Code

Check if there are workplaces on file that are not identified here.
Alternate II. (Grantees Who Are Individuals)
(a) The grantee certifies that, as a condition of the grant, he or she will not engage
in the unlawful manufacture, distribution, dispensing, possession, or use of a
controlled substance in conducting any activity with the grant;

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(b) If convicted of a criminal drug offense resulting from a violation occurring
during the conduct of any grant activity, he or she will report the conviction, in
writing, within 10 calendar days of the conviction, to every grant officer or other
designee, unless the Federal agency designates a central point for the receipt of
such notices. When notice is made to such a central point, it shall include the
identification number(s) of each affected grant.
[55 FR 21690, 21702, May 25, 1990]

By checking this box, the prospective primary participant is providing the
certification set out above.

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Section 20: Certification Regarding Lobbying

Section 20: Certification Regarding Lobbying
The submitter of this application certifies, to the best of his or her knowledge
and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf
of the undersigned, to any person for influencing or attempting to influence an
officer or employee of an agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection with the
awarding of any Federal contract, the making of any Federal grant, the making of
any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be
paid to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this
Federal contract, grant, loan, or cooperative agreement, the undersigned shall
complete and submit Standard Form-LLL, ``Disclosure Form to Report
Lobbying,'' in accordance with its instructions
(3) The undersigned shall require that the language of this certification be
included in the award documents for all subawards at all tiers (including
subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by section 1352, title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than $10,000
and not more than $100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this commitment providing for the United States to
insure or guarantee a loan, the undersigned shall complete and submit Standard
Form-LLL, ``Disclosure Form to Report Lobbying,'' in accordance with its
instructions. Submission of this statement is a prerequisite for making or
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entering into this transaction imposed by section 1352, title 31, U.S. Code. Any
person who fails to file the required statement shall be subject to a civil penalty
of not less than $10,000 and not more than $100,000 for each such failure.
By checking this box, the prospective primary participant is providing the
certification set out above.

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Assurances
Assurances

(1) use the funds available under this title to-(A) conduct outreach activities and provide assistance to low income
households in meeting their home energy costs, particularly those with the lowest
incomes that pay a high proportion of household income for home energy,
consistent with paragraph (5);
(B) intervene in energy crisis situations;
(C) provide low-cost residential weatherization and other cost-effective energyrelated home repair;and
(D)plan, develop, and administer the State's program under this title including
leveraging programs, and the State agrees not to use such funds for any purposes
other than those specified in this title;

(2) make payments under this title only with respect to-(A) households in which one or more individuals are receiving-(i)assistance under the State program funded under part A of title IV of
the Social Security Act;
(ii) supplemental security income payments under title XVI of the Social
Security Act;
(iii) food stamps under the Food Stamp Act of 1977; or
(iv) payments under section 415, 521, 541, or 542 of title 38, United States
Code, or under section 306 of the Veterans' and Survivors' Pension
Improvement Act of 1978; or
(B) households with incomes which do not exceed the greater of (i) an amount equal to 150 percent of the poverty level for such State; or
(ii) an amount equal to 60 percent of the State median income;

(except that a State may not exclude a household from eligibility in a fiscal year
solely on the basis of household income if such income is less than 110 percent
of the poverty level for such State, but the State may give priority to those
households with the highest home energy costs or needs in relation to
household income.
(3) conduct outreach activities designed to assure that eligible households,
especially households with elderly individuals or disabled individuals, or both,
and households with high home energy burdens, are made aware of the
assistance available under this title, and any similar energy-related assistance
available under subtitle B of title VI (relating to community services block grant

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program) or under any other provision of law which carries out programs which
were administered under the Economic Opportunity Act of 1964 before the date
of the enactment of this Act;
(4) coordinate its activities under this title with similar and related programs
administered by the Federal Government and such State, particularly low-income
energy-related programs under subtitle B of title VI (relating to community
services block grant program), under the supplemental security income
program, under part A of title IV of the Social Security Act, under title XX of the
Social Security Act, under the low-income weatherization assistance program
under title IV of the Energy Conservation and Production Act, or under any other
provision of law which carries out programs which were administered under the
Economic Opportunity Act of 1964 before the date of the enactment of this Act;
(5) provide, in a timely manner, that the highest level of assistance will be
furnished to those households which have the lowest incomes and the highest
energy costs or needs in relation to income, taking into account family size,
except that the State may not differentiate in implementing this section between
the households described in clauses 2(A) and 2(B) of this subsection;
(6) to the extent it is necessary to designate local administrative agencies in
order to carry out the purposes of this title, to give special consideration, in the
designation of such agencies, to any local public or private nonprofit agency
which was receiving Federal funds under any low-income energy assistance
program or weatherization program under the Economic Opportunity Act of 1964
or any other provision of law on the day before the date of the enactment of this
Act, except that (A) the State shall, before giving such special consideration, determine that the
agency involved meets program and fiscal requirements established by the State;
and
(B) if there is no such agency because of any change in the assistance
furnished to programs for economically disadvantaged persons, then the State
shall give special consideration in the designation of local administrative agencies
to any successor agency which is operated in substantially the same manner as
the predecessor agency which did receive funds for the fiscal year preceding the
fiscal year for which the determination is made;

(7) if the State chooses to pay home energy suppliers directly, establish
procedures to -(A) notify each participating household of the amount of assistance paid on its
behalf;
(B) assure that the home energy supplier will charge the eligible household, in
the normal billing process, the difference between the actual cost of the home
energy and the amount of the payment made by the State under this title;
(C) assure that the home energy supplier will provide assurances that any
agreement entered into with a home energy supplier under this paragraph will

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contain provisions to assure that no household receiving assistance under this title
will be treated adversely because of such assistance under applicable provisions
of State law or public regulatory requirements; and

(D) ensure that the provision of vendor payments remains at the option of the
State in consultation with local grantees and may be contingent on unregulated
vendors taking appropriate measures to alleviate the energy burdens of eligible
households, including providing for agreements between suppliers and individuals
eligible for benefits under this Act that seek to reduce home energy costs, minimize
the risks of home energy crisis, and encourage regular payments by individuals
receiving financial assistance for home energy costs;

(8) provide assurances that,
(A) the State will not exclude households described in clause (2)(B) of this
subsection from receiving home energy assistance benefits under clause (2), and
(B) the State will treat owners and renters equitably under the program
assisted under this title;

(9) provide that-(A) the State may use for planning and administering the use of funds under
this title an amount not to exceed 10 percent of the funds payable to such State
under this title for a fiscal year; and
(B) the State will pay from non-Federal sources the remaining costs of
planning and administering the program assisted under this title and will not use
Federal funds for such remaining cost (except for the costs of the activities
described in paragraph (16));

(10) provide that such fiscal control and fund accounting procedures will be
established as may be necessary to assure the proper disbursal of and
accounting for Federal funds paid to the State under this title, including
procedures for monitoring the assistance provided under this title, and provide
that the State will comply with the provisions of chapter 75 of title 31, United
States Code (commonly known as the "Single Audit Act");
(11) permit and cooperate with Federal investigations undertaken in accordance
with section 2608;
(12) provide for timely and meaningful public participation in the development of
the plan described in subsection (c);
(13) provide an opportunity for a fair administrative hearing to individuals whose
claims for assistance under the plan described in subsection (c) are denied or
are not acted upon with reasonable promptness; and
(14) cooperate with the Secretary with respect to data collecting and reporting
under section 2610.

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(15) * beginning in fiscal year 1992, provide, in addition to such services as may
be offered by State Departments of Public Welfare at the local level, outreach
and intake functions for crisis situations and heating and cooling assistance that
is administered by additional State and local governmental entities or
community-based organizations (such as community action agencies, area
agencies on aging and not-for-profit neighborhood-based organizations), and in
States where such organizations do not administer functions as of September
30, 1991, preference in awarding grants or contracts for intake services shall be
provided to those agencies that administer the low-income weatherization or
energy crisis intervention programs.
* This assurance is applicable only to States, and to territories whose annual
regular LIHEAP allotments exceed $200,000. Neither territories with annual
allotments of $200,000 or less nor Indian tribes/tribal organizations are subject to
Assurance 15.
(16) use up to 5 percent of such funds, at its option, to provide services that
encourage and enable households to reduce their home energy needs and
thereby the need for energy assistance, including needs assessments,
counseling, and assistance with energy vendors, and report to the Secretary
concerning the impact of such activities on the number of households served,
the level of direct benefits provided to those households, and the number of
households that remain unserved.

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Plan Attachments
PLAN ATTACHMENTS
The following documents must be attached to this application

•

Delegation Letter is required if someone other than the Governor or Chairman Certified this Report.

•

Heating component benefit matrix, if applicable

•

Cooling component benefit matrix, if applicable

•

Minutes, notes, or transcripts of public hearing(s).

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