1 Household Report Long Form

Low Income Home Energy Assistance Program (LIHEAP) Household Report

COMM_LIHEAP_HHR_Long Form_121721.xlsx

OMB: 0970-0060

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Household Report - Long Form






OMB Clearance No.: 0970-0060
Expiration Date: XX/XX/2025
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM
LIHEAP HOUSEHOLD REPORT-LONG FORM
Recipient Information






Recipient Name: FFY:
Contact Person: Phone:
Email Address:
Instructions






The 50 States, District of Columbia, the Commonwealth of Puerto Rico are required to use the LIHEAP Household Report-Long Form in providing household counts for the designated Federal Fiscal Year. The Report consists of the following six sections that are to include unduplicated household counts for both LIHEAP assisted and LIHEAP applicant households.
I. Number of Assisted Households
II. Number of Assisted Households by Poverty Interval
III. Number of Assisted Households by Vulnerable Population
IV. Number of Applicant Households
V. Number of Applicant Households by Poverty Interval
VI. Number of Assisted Households by Young Child Age Category
Except for Section VI, the household counts for LIHEAP assisted and applicant households are required under the LIHEAP statute. Section VI is optional. If LIHEAP funds are used for any other type of service not listed in the sections below, describe the service and the total number of households assisted with that service in the Notes Section.
The required data for LIHEAP assisted households for each State are included in the Department's LIHEAP annual Report to Congress. The required data are also used in measuring LIHEAP targeting performance under the Government Performance and Results Act (GPRA) of 1993, as amended by the GPRA Modernization Act of 2010. As the reported data are aggregated, the information in this report is not considered to be confidential.
Click HERE to read the expanded Household Report - Long Form Instructions.
Do the data below include estimated figures?
If YES, select the appropriate box in column A of Section I and Section IV for each type of assistance that has at least one estimated data entry.
Select One
Yes No
















I. Number of Assisted Households






Number of assisted households
Type of LIHEAP assistance A. Select if estimated data B. Total Number of Households
1. Heating

2. Heating (CARES Act funding)






3. Heating (American Rescue Plan Act funding)






4. Heating (Reserved for other supplemental funding)






5. Cooling

6. Cooling (CARES Act funding)





7. Cooling (American Rescue Plan Act funding)





8. Cooling (Reserved for other supplemental funding)






9. Crisis
a. Year Round

b. Year Round (CARES Act funding)





c. Year Round (American Rescue Plan Act funding)






d. Year Round (Reserved for other supplemental funding)






e. Winter

f. Winter (CARES Act funding)






g. Winter (American Rescue Plan Act funding)






h. Winter (Reserved for other supplemental funding)

i. Summer

j. Summer (CARES Act funding)





k. Summer (American Rescue Plan Act funding)






l. Summer (Reserved for other supplemental funding)






m. Emergency Furnace Repair & Replacement

n. Emergency Furnace Repair & Replacement (CARES Act funding)
o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)

p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)

q. Other Crisis Assistance






r. Other Crisis Assistance (CARES Act funding)






s. Other Crisis Assistance (American Rescue Plan Act funding)






t. Other Crisis Assistance (Reserved for other supplemental funding)






10. Weatherization

11. Weatherization (CARES Act funding)






12. Weatherization (American Rescue Plan Act funding)






13. Weatherization (Reserved for other supplemental funding)






14. Any type of LIHEAP assistance

15. Any type of LIHEAP assistance (CARES Act funding)





16. Any type of LIHEAP assistance (American Rescue Plan Act funding)






17. Any type of LIHEAP assistance (Reserved for other supplemental funding)






18. Bill Payment Assistance

19. Bill Payment Assistance (CARES Act funding)






20. Bill Payment Assistance (American Rescue Plan Act funding)






21. Bill Payment Assistance (Reserved for other supplemental funding)






22. Nominal Payments






23. Nominal Payments (American Rescue Plan Act funding only)






24. Nominal Payments (American Rescue Plan Act funding)






25. Nominal Payments (Reserved for other supplemental funding)






II. Number of Assisted Households by Poverty Interval





Applicable HHS Poverty Guidelines in effect at the beginning of FFY






Type of LIHEAP assistance A. Under 75% poverty B. 75%-100%
poverty
C. 101%-125%
poverty
D. 126%-150%
poverty
E. Over 150% poverty
1. Heating




2. Heating (CARES Act funding)






3. Heating (American Rescue Plan Act funding)






4. Heating (Reserved for other supplemental funding)






5. Cooling




6. Cooling (CARES Act funding)






7. Cooling (American Rescue Plan Act funding)






8. Cooling (Reserved for other supplemental funding)






9. Crisis






a. Year Round




b. Year Round (CARES Act funding)






c. Year Round (American Rescue Plan Act funding)






d. Year Round (Reserved for other supplemental funding)






e. Winter




f. Winter (CARES Act funding)






g. Winter (American Rescue Plan Act funding)






h. Winter (Reserved for other supplemental funding)






i. Summer




j. Summer (CARES Act funding)






k. Summer (American Rescue Plan Act funding)






l. Summer (Reserved for other supplemental funding)






m. Emergency Furnace Repair & Replacement




n. Emergency Furnace Repair & Replacement (CARES Act funding)




o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)




p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)




q. Other Crisis Assistance






r. Other Crisis Assistance (CARES Act funding)






s. Other Crisis Assistance (American Rescue Plan Act funding)






t. Other Crisis Assistance (Reserved for other supplemental funding)






10. Weatherization




11. Weatherization (CARES Act funding)




12. Weatherization (American Rescue Plan Act funding)




13. Weatherization (Reserved for other supplemental funding)




III. Number of Assisted Households by Vulnerable Population






At least one households member who is a member of one the following target groups






Type of LIHEAP assistance A. 60 years or older (elderly) B. Disabled C. Age 5 years or under (young child) D. Elderly, disabled, or young child
1. Heating




2. Heating (CARES Act funding)




3. Heating (American Rescue Plan Act funding)




4. Heating (Reserved for other supplemental funding)




5. Cooling



6. Cooling (CARES Act funding)




7. Cooling (American Rescue Plan Act funding)




8. Cooling (Reserved for other supplemental funding)




9. Crisis






a. Year Round




b. Year Round (CARES Act funding)




c. Year Round (American Rescue Plan Act funding)




d. Year Round (Reserved for other supplemental funding)




e. Winter




f. Winter (CARES Act funding)




g. Winter (American Rescue Plan Act funding)




h. Winter (Reserved for other supplemental funding)




i. Summer




j. Summer (CARES Act funding)




k. Summer (American Rescue Plan Act funding)




l. Summer (Reserved for other supplemental funding)




m. Emergency Furnace Repair & Replacement




n. Emergency Furnace Repair & Replacement (CARES Act funding)




o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)




p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)




q. Other Crisis Assistance






r. Other Crisis Assistance (CARES Act funding)






s. Other Crisis Assistance (American Rescue Plan Act funding)






t. Other Crisis Assistance (Reserved for other supplemental funding)






10. Weatherization



11. Weatherization (CARES Act funding)



12. Weatherization (American Rescue Plan Act funding)



13. Weatherization (Reserved for other supplemental funding)



14. Any type of LIHEAP assistance



15. Any type of LIHEAP assistance (CARES Act funding)



16. Any type of LIHEAP assistance (American Rescue Plan Act funding)



17. Any type of LIHEAP assistance (Reserved for other supplemental funding)



IV. Number of Applicant Households






Number of applicant households






Type of LIHEAP assistance A. Select if estimated data B. Total Number of Households
1. Heating

2. Heating (CARES Act funding)



3. Heating (American Rescue Plan Act funding)



4. Heating (Reserved for other supplemental funding)




5. Cooling

6. Cooling (CARES Act funding)




7. Cooling (American Rescue Plan Act funding)




8. Cooling (Reserved for other supplemental funding)




9. Crisis






a. Year Round

b. Year Round (CARES Act funding)




c. Year Round (American Rescue Plan Act funding)




d. Year Round (Reserved for other supplemental funding)




e. Winter

f. Winter (CARES Act funding)




g. Winter (American Rescue Plan Act funding)



h. Winter (Reserved for other supplemental funding)




i. Summer

j. Summer (CARES Act funding)




k. Summer (American Rescue Plan Act funding)



l. Summer (Reserved for other supplemental funding)




m. Emergency Furnace Repair & Replacement

n. Emergency Furnace Repair & Replacement (CARES Act funding)


o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)

p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)


q. Other Crisis Assistance





r. Other Crisis Assistance (CARES Act funding)






s. Other Crisis Assistance (American Rescue Plan Act funding)






t. Other Crisis Assistance (Reserved for other supplemental funding)






10. Weatherization

11. Weatherization (CARES Act funding)

12. Weatherization (American Rescue Plan Act funding)

13. Weatherization (Reserved for other supplemental funding)

V. Number of Applicant Households by Poverty Interval





Applicable HHS Poverty Guidelines in effect at the beginning of FFY






Type of LIHEAP assistance A. Under 75% poverty B. 75%-100%
poverty
C. 101%-125%
poverty
D. 126%-150%
poverty
E. Over 150% poverty F. Income data unavailable
1. Heating





2. Heating (CARES Act funding)





3. Heating (American Rescue Plan Act funding)





4. Heating (Reserved for other supplemental funding)





5. Cooling





6. Cooling (CARES Act funding)





7. Cooling (American Rescue Plan Act funding)





8. Cooling (Reserved for other supplemental funding)





9. Crisis






a. Year Round





b. Year Round (CARES Act funding)





c. Year Round (American Rescue Plan Act funding)





d. Year Round (Reserved for other supplemental funding)





e. Winter





f. Winter (CARES Act funding)





g. Winter (American Rescue Plan Act funding)





h. Winter (Reserved for other supplemental funding)





i. Summer





j. Summer (CARES Act funding)





k. Summer (American Rescue Plan Act funding)





l. Summer (Reserved for other supplemental funding)





m. Emergency Furnace Repair & Replacement





n. Emergency Furnace Repair & Replacement (CARES Act funding)





o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)





p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)





q. Other Crisis Assistance






r. Other Crisis Assistance (CARES Act funding)






s. Other Crisis Assistance (American Rescue Plan Act funding)






t. Other Crisis Assistance (Reserved for other supplemental funding)






10. Weatherization





11. Weatherization (CARES Act funding)





12. Weatherization (American Rescue Plan Act funding)





13. Weatherization (Reserved for other supplemental funding)





VI. Number of Assisted Households by Young Child Age Category (Optional)






At least one member who is






Type of LIHEAP assistance A. Age 2 years or under B. Age 3 years through 5 years
1. Heating

2. Heating (CARES Act funding)

3. Heating (American Rescue Plan Act funding)

4. Heating (Reserved for other supplemental funding)

5. Cooling

6. Cooling (CARES Act funding)

7. Cooling (American Rescue Plan Act funding)

8. Cooling (Reserved for other supplemental funding)

9. Crisis






a. Year Round

b. Year Round (CARES Act funding)

c. Year Round (American Rescue Plan Act funding)

d. Year Round (Reserved for other supplemental funding)

e. Winter

f. Winter (CARES Act funding)

g. Winter (American Rescue Plan Act funding)

h. Winter (Reserved for other supplemental funding)

i. Summer

j. Summer (CARES Act funding)

k. Summer (American Rescue Plan Act funding)

l. Summer (Reserved for other supplemental funding)

m. Emergency Furnace Repair & Replacement

n. Emergency Furnace Repair & Replacement (CARES Act funding)

o. Emergency Furnace Repair & Replacement (American Rescue Plan Act funding)

p. Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)

q. Other Crisis Assistance






r. Other Crisis Assistance (CARES Act funding)






s. Other Crisis Assistance (American Rescue Plan Act funding)






t. Other Crisis Assistance (Reserved for other supplemental funding)






10. Weatherization

11. Weatherization (CARES Act funding)

12. Weatherization (American Rescue Plan Act funding)

13. Weatherization (Reserved for other supplemental funding)

Remarks






Enter any explanation needed regarding the reliability and/or validity of the above-reported data:






















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 penalities. (U.S. Code, Title 18, Section 1001)







a. Name of Authorized Official:



b. Title of Authorized Official:



c. Signature of Authorized Official:



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