DOE F 540.5 E&I Form - Subgrantee Information Worksheet

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: __________

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:

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:

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.

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