DOE F 540.12 Community Scale Form - QPR

DOE F 540.12 OMB Control No. 1910-5157

Expiration Date: xx/xx/2023

U.S. Department of Energy

WEATHERIZATION ASSISTANCE PROGRAM

COMMUNITY SCALE WEATHERIAZATION PILOT

QUARTERLY PROGRAM REPORT

Grantee: _______________ Budget period: / / - / / Grant Number:________________

I. GRANT OUTLAYS - FUNDS SUBJECT TO DOE PROGRAM RULES (rounded to the nearest dollar)

Reporting Period Quarter	/ - /	/ - /	/ - /	/ - /	Total To Date
	Q1	Q2	Q3	Q4
A. OUTLAYS BY FUND SOURCE
DOE
Other funds included in grant budget, section A
Total Grant Outlays
B. OUTLAYS BY FUNCTION
Administration
Health and Safety
Training and Technical Assistance
Program Operations
Liability Insurance
Financial Audits
Total Grant Outlays
C. OUTLAYS IN UNDERSERVED COMMUNITIES
DOE funds
Other funds included in grant budget, section A
Total Grant Outlays

Notes: Total grant outlays must equal outlays reported on the Federal Financial Report, line 10.e.

II. GRANT PRODUCTION

Quarter	Q1	Q2	Q3	Q4	Total to Date
A. TOTAL CS UNITS (includes other funds if included in DOE budget) – Planned ##
UNITS IN UNDERSERVED COMMUNITIES – Planned ##
UNITS BY LEVEL OF HOUSEHOLD INCOME
Up to 50%
51 – 100%
101 – 150%
151 – 200%
3. UNITS BY TYPE
Owner-Occupied Single Family
Renter-Occupied Single Family
Owner-Occupied 2-4 units per site
Renter Occupied 2-4 units per site
Multifamily, 5 or more units per site
Owner-Occupied Manufactured Home
Renter-Occupied Manufactured Home
Shelter
4. UNITS BY PRIMARY HEATING FUEL**
Natural Gas
Fuel Oil
Electricity
Propane/LPG
Kerosene
Wood
Other Fuel
No Heating System
5. UNITS BY OCCUPANCY
Elderly-Occupied
Disabled-Occupied
Native American-Occupied
Children-Occupied
High Residential Energy User
Household with a High Energy Burden
B. LEVERAGED UNITS (units completed with other funds not included in DOE budget)
C. TOTAL PEOPLE ASSISTED WITH GRANT FUNDS (all funds in approved budget)
Elderly
Persons with Disabilities
Native Americans
Children

** “Primary Heating Fuel” is the fuel that provides the most space heat and/or cooling in the home.

III. COMMUNITY SCALE METRICS

Quarter	Q1	Q2	Q3	Q4	Total to Date
Client Education (total hours)
Number of Minority Serving Institutions, Minority Business Enterprises, Minority Owned Businesses, Woman Owned Businesses, Veteran Owned Businesses Contracting with Grantee
ENERGY BURDEN
Total Annual Household Energy Expenditures (in dollars)
Total Annual Household Energy Expenditures in Underserved Communities (in dollars)

IV. COMMENTS

Submitted by_________________________________________________________________ Date_____________

Type name___________________________________________________________________

Title ___________________________________________________________________

OMB Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 4 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

COMMUNITY SCALE WEATHERIAZATION PILOT

QUARTERLY PROGRAM REPORT

INSTRUCTIONS

The Quarterly Program Report format is designed to gather production and expenditure data. This report is to be submitted quarterly to the applicable Department of Energy 30 days after the end of the reporting period.

1. GRANT OUTLAYS - FUNDS SUBJECT TO DOE CS PROGRAM RULES

   1. By fund source: Outlays this quarter and program year to date for

      1. DOE funds

      2. All other funds listed in the grant budget, Section A, including federal, state, local, and private funds that are part of the approved DOE grant budget.

   2. By function: Outlays this quarter and program year to date for each function in the DOE grant budget, section B. Total must equal total in A.2 above.

   3. In underserved communities: Outlays in underserved communities this quarter and program year to date for

      1. DOE funds

      2. All other funds listed in the grant budget, Section A, including federal, state, local, and private funds that are part of the approved DOE grant budget.

2. GRANT PRODUCTION

Enter figures only for the quarter being reported except to correct previous quarter information.

1. CS units completed this quarter with all funds included in the approved DOE grant budget, all sources.

   1. Units in underserved communities: Total number of units completed this quarter in underserved communities. The sum should be less than or equal to the total units completed with funds in the approved DOE budget.

   2. Units by level of household income: Number of completed units this quarter by level specified. The sum should equal total units completed with funds in the approved DOE budget.

   3. Units by type: Number completed this quarter by type specified. The sum should equal total units completed with funds in the approved DOE budget. A completed unit in a building containing five or more units should be reported as a Multi-Family unit. A completed unit in a building containing four units or less should be reported under one of the two Single-Family categories.

   4. Units by primary heating fuel: Number of units completed by category of primary heating fuel. Primary heating fuel is the fuel that provides the most space heat in the home.

   5. Units by occupant: Number of units completed by category of occupant. The sum will not equal total units completed.

2. Persons assisted with funds included in the DOE grant budget, all sources: Total and by category. Sum of persons by category will not equal total persons assisted.

3. Leveraged units completed with other funds not included in the DOE budget, provided any part of the definition of an CS unit has been met.

3. CS METRICS

   1. Client Education: Total hours provided this quarter.

   2. Number of MBEs and Minority, Women or Veteran-Owned Businesses: Number of new contracts executed by Grantee this quarter, and year to date.

C. Energy Burden: CS Metrics for Grantees with awards to install measures in eligible households. This is a heading, no data reported in this row.

1. Units by Household Energy Burden: For units completed this quarter, report the number of units by categories provided. The sum should equal the total units completed with funds in the approved DOE budget.

2. Total Annual Household Energy Expenditures: For units completed this quarter, report the sum of each household’s annual energy use expenses (in dollars) prior to installation of any CS measures.

3. Total Annual Household Energy Expenditures: For units completed in underserved communities this quarter, report the sum of each household’s annual energy use expenses (in dollars) prior to installation of any CS measures.

4. COMMENTS

Include here any additional information needed to clarify grant outlays and production reported this quarter.

Submitted by: Signature of the person submitting the report.

Date signed.

Typed name and title of the submitter.

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 4 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.