Information Collection

State Grantees Module 1

IC 230200 under ICR 202112-0970-006 · OMB 0970-0449.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0449 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 State Grantees Module 1	Form
LIHEAP Performance Data Form Instructions – CLEAN.docx	Instruction
LIHEAP Performance Data Form Instructions – CLEAN.docx	Instruction
1 LIHEAP Performance Data ADMIN_LIHEAP_OMBSSAtt2Form_FY2021.xlsx	Form
1 LIHEAP Performance Data ADMIN_LIHEAP_OMBSSAtt2Form_FY2021.xlsx	Form
ADMIN_LIHEAP_LPDFPopupInstrs_FY2021.docx Popup instructions for LPDF	IC Document
ADMIN_LIHEAP_LPDFPopupInstrs_FY2021.docx Popup instructions for LPDF	IC Document

IC Title:

State Grantees Module 1

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 Performance Data	ADMIN_LIHEAP_OMBSSAtt2Form_FY2021.xlsx		Yes	Yes	Fillable Printable
Instruction			LIHEAP Performance Data Form Instructions â CLEAN.docx		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: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	1,836	1,836
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Popup instructions for LPDF	ADMIN_LIHEAP_LPDFPopupInstrs_FY2021.docx	12/13/2021

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