DOE F 540.4 Community Scale Form - T&TA. Monitoring, and Leveraging

DOE F 540.4
(04-05)

OMB #
Expiration Date:

1910-5157
xx/xx/2023

U.S. Department of Energy
WEATHERIZATION ASSISTANCE PROGRAM
ANNUAL TRAINING, TECHNICAL ASSISTANCE, MONITORING, AND LEVERAGING REPORT
State

Program Year
Reporting Period

/

/

Grant Number
-

/

/

TRAINING AND TECHNICAL ASSISTANCE ACTIVITIES
Please describe the training and technical assistance (T&TA) activities conducted during the past program year.

DOE F 540.4
(04-05)

OMB #
Expiration Date:

U.S. Department of Energy
WEATHERIZATION ASSISTANCE PROGRAM
ANNUAL TRAINING, TECHNICAL ASSISTANCE, MONITORING, AND LEVERAGING REPORT
State

Program Year
Reporting Period

/

/

Grant Number
-

/

/

MONITORING ACTIVITIES
Please list the subgrantees monitored during the reporting period and indicate the focus and significant findings of
each monitoring activity, as appropriate.

DOE F 540.4
(04-05)

OMB #
Expiration Date:

U.S. Department of Energy
WEATHERIZATION ASSISTANCE PROGRAM
ANNUAL TRAINING, TECHNICAL ASSISTANCE, MONITORING, AND LEVERAGING REPORT
State

Program Year
Reporting Period

/

/

Grant Number
-

/

/

LEVERAGING ACTIVITIES
For each leveraging activity, states are to describe the type of project, the amount and source of funding (Note:
the number of leveraged completed units will be reported on line D of the Quarterly Program Report).

Submitted by
Type name
Title

Date

OMB Burden Disclosure Statement
This data is being collected to administer the Department of Energy Weatherization Assistance Program. The data you supply
will be used to respond to congressional, budget and general public inquiries of the program.
Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Chief Information Officer, Records management Division,
IM-11, Paperwork Reduction Act Project (1910-XXXX), U.S. Department of Energy, 19901 Germantown Road, MD 20874 and
to the Office of Management and Budget, OIRA, Paperwork Reduction Project (1910-XXXX), Washington, DC 20503.

U.S. Department of Energy
WEATHERIZATION ASSISTANCE PROGRAM
ANNUAL FILE WORKSHEET
INSTRUCTIONS
The Annual Training, Technical Assistance, Monitoring, and Leveraging Report is to be submitted annually, 30 days after the
end of the reporting period.
State:
Program Year:
Grant number:
Reporting Period:

Name of state or tribal organization submitting the report.
The beginning and ending dates (mm/dd/yy) for the Program Year reported.
The seven-digit Federal identification number assigned to the grant (R999999).
The starting and ending dates (mm/dd/yy) for the reporting period for the WAP program year.

Item

Explanation

Training and Technical Assistance
Activities

Identify the training and technical assistance activities conducted during the
past program year; may also include publications such as brochures, or articles
that highlight the states’ weatherization activities

Monitoring Activities

Identify the subgrantees monitored during the reporting period and indicate
the focus and significant findings of each monitoring activity, as appropriate

Leveraging Activities

Identify and describe the type of projects executed and the amount and
source of funding successfully leveraged

Submitted by: Signature of the person submitting the report.
Date signed.
Typed name and title of the submitter.