Form 1 LIHEAP Quarterly Performance and Management Report

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Overview

Quarterly 1&2
Quarterly Q3
Quartley Q4
Reference Tables

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Sheet 1: Quarterly 1&2

OMB Control No. xxxx-xxxx		Expiration Date: xx/xx/xxxx
Low Income Home Energy Assistance Program Quarterly Performance and Management Report
Recipient Information
Recipient Name:
Contact Name:
Contact Phone Number:
Contact Email:
First Quarterly Performance and Management Report (October 1- March 31)
I. Total Households Assisted
	A. Total Households Q1 &Q2
1. Number of assisted households
2. Number of assisted households during the same period last year
II. Performance Management
	A. Total Occurrences Q1 & Q2
1. Number of Occurences of households where LIHEAP prevented the loss of home energy.
2. Number of Occurences of households where LIHEAP restored home energy.
III. Estimated Use of LIHEAP Funds
	Obligations by LIHEAP Funding Source (if applicable)
	A. LIHEAP FY 2022 Non-Supplemental (released November 1, 2021)	B. American Rescue Plan Act, 2021 (released May 4, 2021)	C. {Reserved, if applicable} Other Supplemental Allotment
1. Amount of funds obligated	0	0	0
IV. LIHEAP Program Implementation and Support
For questions 1-7, please select Yes or No from the dropdown menu in column B. If the answer is yes, please explain what changes were made, when they were made, and why they were made in the space provided below each question.
1. Since submitting your Grantee Plan, have you made any changes to your income eligibility requirements?
Provide a brief explaination here:
2. Since submitting your Grantee Plan, have you made any changes to your income verification/documentation requirements?
Provide a brief explaination here:
3. Since submitting your Grantee Plan, have you made any changes to your outreach strategies?
Provide a brief explaination here:
4. Since submitting your Grantee Plan, have you made any changes to your benefit matrix and/or have you increased your crisis maximum amounts? *Note: for grant recipients that have made changes in both of these areas, please indicate the changes made to both areas and whether the changes were made for heating or cooling assistance or both.
Provide a brief explaination here:
5. Since submitting your Grantee Plan, have you made any changes to how you are prioritizing vulnerable populations (i.e., the elderly, disabled, and young children)?
Provide a brief explaination here:
6. Since submitting your Grantee Plan, have you made any other changes to your policies on arrearage forgiveness (i.e., paying off a client’s outstanding energy debt in full)?
Provide a brief explaination here:
7. Since submitting your Grantee Plan, have you made any other changes to your LIHEAP policies?
Provide a brief explaination here:
8. Are you collaborating or coordinating with other utility assistance programs (i.e., the Emergency Rental Assistance Program, Community Services Block Grant, Utility funded energy assisted programs, Homeowners Assistance Fund)? If so, please provide a brief explanation of your colloboration/coordination efforts.
Response:
9. Do you have any challenges or training and/or technical assistance needs that you would like the Office of Community Services' Division of Energy Assistance to offer support for? If so, please list these in the response.
Response:
10. Please provide a quote on the impact of LIHEAP from a member of a LIHEAP household.
Response:
V. Remarks
1. Enter any explanation needed regarding the reliability and/or validity of the above-reported data.
Response:
VI. Certification
Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)
a. Name of Authorized Official:
b. Title of Authorized Official:
c. Signature of Authorized Official:
d. Date Signed:

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Sheet 2: Quarterly Q3

OMB Control No. xxxx-xxxx		Expiration Date: xx/xx/xxxx
Low Income Home Energy Assistance Program Quarterly Performance and Management Report
Recipient Information
Recipient Name:
Contact Name:
Contact Phone Number:
Contact Email:
Third Quarterly Performance and Management Report (April 1- June 30)
I. Total Households Assisted
	A. Total Households Q3	B. Total Cumulative Households
1. Number of assisted households		0
2. Number of assisted households during the same period last year		0
II. Performance Management
	A. Total Occurrences Q3
1. Number of Occurences of households where LIHEAP prevented the loss of home energy.
2. Number of Occurences of households where LIHEAP restored home energy.
III. Estimated Uses of LIHEAP Funds
	Obligations by LIHEAP Funding Source (if applicable)
	A. LIHEAP FY 2022 Non-Supplemental (released November 1, 2021)	B. American Rescue Plan Act, 2021 (released May 4, 2021)	C. {Reserved, if applicable} Other Supplemental Allotment
1. Amount of funds obligated	0	0	0
IV. LIHEAP Program Implementation and Support
1. Since reporting in Q 1 & 2, have you made any new/other changes to your income eligibility requirements?
Provide a brief explaination here:
2. Since reporting in Q 1 & 2, have you made any new/other changes to your income verification/documentation requirements?
Provide a brief explaination here:
3. Since reporting in Q 1 & 2, have you made any new/other changes to your outreach strategies?
Provide a brief explaination here:
4. Since reporting in Q 1 & 2, have you made any new/other changes to your benefit matrix and/or have you increased your crisis maximum amounts? *Note: for grant recipients that have made changes in both of these areas, please indicate the changes made to both areas and whether the changes were made for heating or cooling assistance or both.
Provide a brief explaination here:
5. Since reporting in Q 1 & 2, have you made any new/other changes to how you are prioritizing vulnerable populations (i.e., the elderly, disabled, and young children)?
Provide a brief explaination here:
6. Since reporting in Q 1 & 2, have you made any other new/other changes to your policies on arrearage forgiveness (i.e., paying off a client’s outstanding energy debt in full)?
Provide a brief explaination here:
7. Since reporting in Q 1 & 2, have you made any other new/other changes to your LIHEAP policies?
Provide a brief explaination here:
8. Please provide any information on the results, if any, of the changes you reported in section IV for Quarters 1 and 2.
Response:
9. Are you starting or continuing to collaborate with other utility assistance programs (e.g., Emergency Rental Assistance Program), if so please indicate how this collaboration is working and provide any examples of successful collaboration.
Response:
10. Please provide a quote on the impact of LIHEAP in your state/territory/tribe from a staff member, government official, or stakeholder.
Response:
V. Remarks
1. Enter any explanation needed regarding the reliability and/or validity of the above-reported data.
Response:
VI. Certification
Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)
a. Name of Authorized Official:
b. Title of Authorized Official:
c. Signature of Authorized Official:
d. Date Signed:

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Sheet 3: Quartley Q4

OMB Control No. xxxx-xxxx		Expiration Date: xx/xx/xxxx
Low Income Home Energy Assistance Program Quarterly Performance and Management Report
Recipient Information
Recipient Name:
Contact Name:
Contact Phone Number:
Contact Email:
Fourth Quarterly Performance and Management Report (July 1- September 30)
I. Total Households Assisted
	A. Total Households Q4	B. Total Cumulative Households
1. Number of assisted households		0
2. Number of assisted households during the same period last year		0
II. Performance Management
	A. Total Occurrences Q4
1. Number of Occurences of households where LIHEAP prevented the loss of home energy.
2. Number of Occurences of households where LIHEAP restored home energy.
III. Estimated Uses of LIHEAP Funds
	Obligations by LIHEAP Funding Source (if applicable)
	A. LIHEAP FY 2022 Non-Supplemental (released November 1, 2021)	B. American Rescue Plan Act, 2021 (released May 4, 2021)	C. {Reserved, if applicable} Other Supplemental Allotment
1. Amount of funds obligated	0	0	0
IV. LIHEAP Program Implementation and Support
1. If you made any changes to your income eligibility requirements this fiscal year, what was the result of those changes?
Provide a brief explaination here:
2. If you made any changes to your income verification/documentation requirements this fiscal year, what was the result of those changes?
Provide a brief explaination here:
3. If you made any changes to your outreach strategies this fiscal year, what was the result of those changes?
Provide a brief explaination here:
4. If you made any changes to your benefit matrix and/or your crisis maximum amounts this fiscal year, what was the result of those changes? *Note: for grant recipients that made changes in both of these areas, please indicate the results of each change and whether the changes/results were for heating or cooling assistance or both.
Provide a brief explaination here:
5. If you made any changes to how you are prioritizing vulnerable populations (i.e., the elderly, disabled, and young children) this fiscal year, what was the result of those changes?
Provide a brief explaination here:
6. If you made any changes to your policies on arrearage forgiveness (i.e., paying off a client’s outstanding energy debt in full) this fiscal year, what was the result of those changes?
Provide a brief explaination here:
7. If you made any changes to your other LIHEAP policies this fiscal year, what was the result of those changes?
Provide a brief explaination here:
8. Describe up to three notable accomplishments/successes achieved by LIHEAP implementation during this fiscal year. Please include a participant success story, if applicable.
Response:
9. Describe any challenges with administering LIHEAP this year.
Response:
10. Please list and describe up to three lessons learned during this past year as it relates to administering LIHEAP.
Response:
11. What can OCS do to better assist you in the upcoming fiscal year?
Response:
12. Please provide a quote on the impact of LIHEAP from a utility provider.
Response:
V. Remarks
1. Enter any explanation needed regarding the reliability and/or validity of the above-reported data.
Response:
VI. Certification
Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)
a. Name of Authorized Official:
b. Title of Authorized Official:
c. Signature of Authorized Official:
d. Date Signed:

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Sheet 4: Reference Tables

Yes

No