1 Household Report Short Form

OMB Clearance No.: 0970-0060 Expiration Date: XX/XX/2025 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-SHORT FORM
Recipient Name:						FFY:
Contact Person:						Phone:
Email Address:
The LIHEAP Household Report-Short Form is for use by all direct-grant Indian tribes/tribal organizations
a. You can find the full instructions for submitting this report - Click HERE
Required Data
I. TYPE OF ASSISTANCE		A. Number of assisted households
1. Heating
3. Heating (American Rescue Plan Act funding)
4. Heating (Reserved for other supplemental funding)
5. Cooling
7. Cooling (American Rescue Plan Act funding)
8. Cooling (Reserved for other supplemental funding)
9. Winter / year-round crisis
11. Winter / year-round crisis (American Rescue Plan Act funding)
12. Winter / year-round crisis (Reserved for other supplemental funding)
13. Summer crisis
15. Summer crisis (American Rescue Plan Act funding)
16. Summer crisis (Reserved for other supplemental funding)
17. Weatherization
19. Weatherization (American Rescue Plan Act funding)
20. Weatherization (Reserved for other supplemental funding)
21. Other crisis assistance
23. Other crisis assistance (American Rescue Plan Act funding)
24. Other crisis assistance (Reserved for other supplemental funding)
II: Number of Assisted Households Owner/Renter Status
A. Owner/Renter Status	Number of Household Applicants
1. Own
2. Rent with utilities billed separately
3. Rent with utilities in rental fee
4. Other
5. Unknown/not Reported
4. TOTAL (Auto Calculated)	0
III. Number of Assisted Households Applicants by Race and Ethnicity
Number of Assisted Household Applicants by Race and Ethnicity
A. Ethnicity	Number of Household Applicants
1. Hispanic, Latino, or Spanish Origins
2. Not Hispanic, Latino, or Spanish Origins
3. Unknown/not reported
4. TOTAL (Auto Calculated)	0
B. Race	Number of Household Applicants
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
6. Multi-race (two or more of the above)
7. Other
8. Unknown/not reported
9. TOTAL (Auto Calculated)	0
IV. Number of Assisted Household Applicants by Gender	Number of Household Applicants
1. Self Identified Male
2. Self Identified Female
3. Other
4. Unknown/not reported
5. TOTAL (Auto Calculated)	0
V. Assisted Household Members by Race and Ethnicity*
A. Ethnicity	Number of Household Members
1. Hispanic, Latino, or Spanish Origins
2. Not Hispanic, Latino, or Spanish Origins
3. Unknown/not reported
4. TOTAL (Auto Calculated)	0
*See Instructions
B. Race*	Number of Household Members
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
6. Multi-race (two or more of the above)
7. Other
8. Unknown/not reported
9. TOTAL (Auto Calculated)	0
*See Instructions
VI. Assisted Household Members by Gender*	Number of Household Members
1. Self Identified Male
2. Self Identified Female
3. Other
4. Unknown/not reported
5. TOTAL (Auto Calculated)	0
Remarks
Please enter any explanation needed of the above-reported data:
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:
d. Telephone:
e. Email address:
f. Date Submitted: