DOE F 540.5 E&I Form - Subgrantee Information Worksheet

Weatherization Assistance Program Sub-programs

DOE F 540.5 E&I Form - Subgrantee Information Worksheet- Final

Weatherization Assistance Program Sub-programs - State, Local or Tribal Government

OMB: 1910-5157

Document [docx]
Download: docx | pdf

DOE F 540.5 OMB Control No. 1910-5157

Expiration date: XX/XX/2023


U.S. Department of Energy

WEATHERIZATION ASSISTANCE PROGRAM ENHANCEMENT AND INNOVATION (E&I)

SUBGRANTEE INFORMATION WORKSHEET


Grant #: __________ State: ___________ Program Year: __________


Shape1

Duns Number: __________________________________ Name: __________________________________________


Phone: ________________________________________ Email: __________________________________________


Address 1: ___________________________________________ Contact: ________________________________________


Address 2: ___________________________________________ Fax: ___________________________________________


City: __________________________________________________ State: ________________ Zip Code: _____________

Tentative allocation:



Counties served:


Congressional Districts:

Planned units:






Type of organization:






Sources of Labor:










Shape2

Duns Number: __________________________________ Name: __________________________________________


Phone: ________________________________________ Email: __________________________________________


Address 1: ___________________________________________ Contact: ________________________________________


Address 2: ___________________________________________ Fax: ___________________________________________


City: __________________________________________________ State: ________________ Zip Code: _____________

Tentative allocation:



Counties served:


Congressional Districts:

Planned units:






Type of organization:






Sources of Labor:










Shape3

Duns Number: __________________________________ Name: __________________________________________


Phone: ________________________________________ Email: __________________________________________


Address 1: ___________________________________________ Contact: ________________________________________


Address 2: ___________________________________________ Fax: ___________________________________________


City: __________________________________________________ State: ________________ Zip Code: _____________

Tentative allocation:



Counties served:


Congressional Districts:

Planned units:






Type of organization:






Sources of Labor:










OMB Burden Disclosure Statement


Public reporting burden for this collection of information is estimated to average 2 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 Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.


PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.


Shape4
Shape5
U.S. Department of Energy

WEATHERIZATION ASSISTANCE PROGRAM

WAP SUBGRANTEE INFORMATION

INSTRUCTIONS






Item


Explanation



DUNS Number


Enter the unique Dun & Bradstreet (DUNS) number associated with the subgrantee (Required)



Name


Name of subgrantee contracted by the state to perform weatherization services (Required)




Contact

Name of contact at the agency




Phone, Email, Address, Fax, City, State, and Zip Code


Self-explanatory (Required)




Tentative Allocation

Self-explanatory (Required). Tentative allocation can include non-DOE funding if included in the DOE budget.




Planned Units

Self-explanatory (Required). Planned units can include those completed with non-DOE funds if included in DOE budget.




Type of Organization



Sources of Labor


Local action agency, non-profit, tribal organization, unit of local government (Required)


Crews, contractors, or both (Required)



Counties Served

Self-explanatory (Required)




Congressional Districts

Self-explanatory (Required)



Complete this information for each subgrantee.



PAPERWORK REDUCTION ACT BURDEN DISCLOSURE STATEMENT


This data is being collected to be used by program staff to track Community Scale recipients’ activities, their progress in achieving scheduled milestones, and funds expended. The data you supply will be used to enable program staff to provide required or requested information on program activities to OMB, Congress, and the public.


Public reporting burden for this collection of information is estimated to average 2 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project 1910-5157, U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project 1910-5157, Washington, DC  20503.


Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number.


Submission of this data is required.




V - 21 Application Package – December 2004

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorJeff
File Modified0000-00-00
File Created2022-02-28

© 2024 OMB.report | Privacy Policy