Mandatory Grant Application SF-424
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
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* 1.a. Type of Submission:
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* 1.b. Frequency:
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* 1.c. Consolidated Application/ Plan/Funding Request?
Explanation: |
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2. Date Received: |
State Use Only: |
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3. Applicant Identifier: |
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4a. Unique Entity Identifier (UEI) |
5. Date Received By State: |
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4b. Federal Award Identifier: |
6. State Application Identifier: |
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7. APPLICANT INFORMATION |
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* a. Legal Name: |
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* b. Address: |
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* Street 1: |
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Street 2: |
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* City: |
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County: |
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* State: |
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Province: |
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* Country: |
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* Zip / Postal Code: |
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c. Organizational Unit: |
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Department Name:
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Division Name:
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d. Name and contact information of person to be contacted on matters involving this application (person will be listed on the Notice of Funding Awards and on the U.S. Department of Health and Human Services’ LIHEAP contact list webpage): |
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* First Name:
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* Last Name:
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Title:
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Organizational Affiliation:
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* Telephone Number:
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Fax Number |
* Email:
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* 8. TYPE OF APPLICANT:
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a. Is the applicant and Tribal Consortium if yes, please attach at least one of the following documentation:
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Catalog of Federal Domestic Assistance Number: |
CFDA Title: |
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9. CFDA Numbers and Titles |
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10. Descriptive Title of Applicant's Project |
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11. Areas Affected by Funding: |
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12. CONGRESSIONAL DISTRICTS OF APPLICANT: |
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13. FUNDING PERIOD: |
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a. Start Date:
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b. End Date:
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* 14. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS? |
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a. This submission was made available to the State under the Executive Order 12372 |
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Process for Review on : |
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b. Program is subject to E.O. 12372 but has not been selected by State for review. |
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c. Program is not covered by E.O. 12372. |
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* 15. Is The Applicant Delinquent On Any Federal Debt?
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If yes, explain: |
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16. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)
**I
Agree
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** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions. |
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17a. Typed or Printed Name and Title of Authorized Certifying Official
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17c. Telephone (area code, number and extension)
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17d. Email Address
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17b. Signature of Authorized Certifying Official
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17e. Date Report Submitted (Month, Day, Year)
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Attach supporting documents as specified in agency instructions. |
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Section 1 - Program Components
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
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Department of Health and Human Services Administration for Children and Families Office of Community Services Washington, DC 20201
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 OMB Approval No. 0970-0075 Expiration Date: 12/31/2023
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Use of this model plan is optional. However, the information requested is required in order to receive a Low Income Home Energy Assistance Program (LIHEAP) grant. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. |
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Section 1 Program Components
Program Components, 2605(a), 2605(b)(1) - Assurance 1, 2605(c)(1)(C) |
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1.1 Check which components you will operate under the LIHEAP program. (Note: You must provide information for each component designated here as requested elsewhere in this plan.) |
Dates of Operation |
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Start Date |
End Date |
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Heating assistance |
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Cooling assistance |
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Weatherization assistance |
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Summer Crisis Assistance |
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Winter Crisis Assistance |
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Year round crisis assistance |
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Provide further explanation for the dates of operation, if necessary |
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Estimated Funding Allocation, 2604(C), 2605(k)(1), 2605(b)(9), 2605(b)(16) - Assurances 9 and 16 |
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1.2 Estimate what amount of available LIHEAP funds will be used for each component that you will operate: The total of all percentages must add up to 100%. |
Percentage ( % ) |
Prior year totals (autopopulate) |
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Heating assistance |
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Cooling assistance |
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Summer crisis assistance |
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Winter crisis assistance |
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Year round crisis assistance |
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Weatherization assistance |
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Carryover to the following federal fiscal year |
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Administrative and planning costs |
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Services to reduce home energy needs including needs assessment (Assurance 16) |
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Used to develop and implement leveraging activities |
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TOTAL |
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Tribal grant recipients: direct-grant tribes, tribal organizations or territories with allotments of $20,000 or less may use for planning and administration up to 20% of the funds payable. Grant recipients that are direct-grant tribes, tribal organizations or territories with allotments over $20,000 may use for planning and administration purposes up to 20% of the first $20,000 (or $4,000) plus 10% of the funds payable that exceeds $20,000. Any administrative costs in excess of these limits must be paid from non-Federal sources. |
Alternate Use of Crisis Assistance Funds, 2605(c)(1)(C) |
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1.3 The funds reserved for winter crisis assistance that have not been expended by March 15 will be reprogrammed to: |
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Heating assistance |
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Cooling assistance |
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Weatherization assistance |
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Other (specify:) |
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Categorical Eligibility, 2605(b)(2)(A) - Assurance 2, 2605(c)(1)(A), 2605(b)(8A) - Assurance 8 |
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1.4
Do
you
consider
households
categorically
eligible
if
at least one
household
member
receives
at least
one
of
the
following
categories
of
benefits
in
the
left
column
below?
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If you answered "Yes" to question 1.4, you must complete the table below and answer questions 1.5 and 1.6. |
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Heating |
Cooling |
Crisis |
Weatherization |
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TANF |
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SSI |
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SNAP |
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Means-tested Veterans Programs |
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1.4 a. Provide your definition of categorical eligibility. Please explain how households are categorically eligible (i.e. do all household members need to receive the benefits or just one member, is there a data exchange in place?) and how categorical eligibility streamlines the LIHEAP application process. |
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1.5
Do you automatically enroll households without a direct annual
application?
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If Yes, explain: |
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1.6 How do you ensure there is no difference in the treatment of categorically eligible households from those not receiving other public assistance when determining eligibility and benefit amounts? |
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SNAP Nominal Payments |
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1.7a
Do you allocate LIHEAP funds toward a nominal payment for SNAP
households?
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If you answered "Yes" to question 1.7a, you must provide a response to questions 1.7b, 1.7c, and 1.7d. |
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1.7b Amount of Nominal Assistance: $0.00 |
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1.7c Frequency of Assistance |
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Once Per Year |
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Once every five years |
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Other - Describe: |
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1.7d How do you confirm that the household receiving a nominal payment has an energy cost or need? |
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Determination of Eligibility - Countable Income |
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1.8. In determining a household's income eligibility for LIHEAP, do you use gross income or net income ? |
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Gross Income |
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Net Income |
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Other – Describe: |
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1.9. Select all the applicable forms of countable income used to determine a household's income eligibility for LIHEAP |
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Wages |
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Self - Employment Income |
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Contract Income |
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Payments from mortgage or Sales Contracts |
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Unemployment insurance |
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Strike Pay |
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![]() Social Security Administration (SSA ) benefits |
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Including Medicare deduction |
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Excluding Medicare deduction |
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Supplemental Security Income (SSI ) |
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Retirement / pension benefits |
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General Assistance benefits |
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Temporary Assistance for Needy Families (TANF) benefits |
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Loans that need to be repaid |
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Cash gifts |
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Savings account balance |
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One-time lump-sum payments, such as rebates/credits, winnings from lotteries, refund deposits, etc. |
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Jury duty compensation |
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Rental income |
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Income from employment through Workforce Investment Act (WIA) |
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Income from work study programs |
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Alimony |
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Child support |
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Interest, dividends, or royalties |
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Commissions |
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Legal settlements |
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Insurance payments made directly to the insured |
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Insurance payments made specifically for the repayment of a bill, debt, or estimate |
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Veterans Administration (VA) benefits |
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Earned income of a child under the age of 18 |
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Balance of retirement, pension, or annuity accounts where funds cannot be withdrawn without a penalty. |
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Income tax refunds |
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Stipends from senior companion programs, such as VISTA |
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Funds received by household for the care of a foster child |
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Ameri-Corp Program payments for living allowances, earnings, and in-kind aid |
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Reimbursements (for mileage, gas, lodging, meals, etc.) |
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Other |
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If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
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1.10
Do you have an online application process
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1.10a If yes, describe the type of online application (select all boxes that apply |
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A PDF version of the application is available online and can be downloaded, filled out and mailed, emailed, dropped off in-person or faxed in for processing. |
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A state-wide online application that allows a customer to complete data entry and submit an application electronically for processing |
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One or more local subgrant recipients have an online applications that allows a customer to complete data entry and submit an application electronically for processing |
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Online application that is also mobile friendly |
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Other, please describe |
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Please include a link to a state-wide application, if available: |
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1.10b
Can all program components be applied for online?
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If no, explain which components can and cannot be applied for online: |
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1.11
Do you have a process for conducting and completing applications
by phone:
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1.12
Do you or any of your subrecipients require in person
appointments in order to apply?
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If yes, please provide more information regarding why in-person appointments are required and in what circumstances they are required. |
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1.13 How can applicants submit documentation for verification? Select all that apply: |
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In-person |
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Portal application |
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Other, describe: |
Section 2 - HEATING ASSISTANCE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
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Section 2 - Heating Assistance |
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Eligibility, 2605(b)(2) - Assurance 2 |
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2.1 Designate the income eligibility threshold used for the heating component: |
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Add |
Household size |
Eligibility Guideline |
Eligibility Threshold |
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2.2 Do you have additional eligibility requirements for heating assistance? |
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2.3 Check the appropriate boxes below and describe the policies for each. |
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Do you require an Assets test ? |
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If yes, describe: |
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Do you have additional/differing eligibility policies for: |
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Renters? |
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If yes, describe: |
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Renters Living in subsidized housing ? |
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If yes, describe: |
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Renters with utilities included in the rent ? |
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If yes, describe: |
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Do you give priority in eligibility to: |
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Older adults? |
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If yes, describe: |
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Individuals with a disability? |
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If yes, describe: |
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Young children? |
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If yes, describe: |
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Households with high energy burdens ? |
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If yes, describe: |
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Other? |
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If yes, describe: |
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Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B) |
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2.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.
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2.5 Check the variables you use to determine your benefit levels. (Check all that apply): |
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Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B) |
2.6 Describe estimated benefit levels for the fiscal year for which this plan applies. Please note, the maximum and minimum benefits must be shown in the payment matrix. |
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Minimum Benefit |
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Maximum Benefit |
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2.7
Do you provide in-kind (e.g., blankets, space heaters) and/or
other forms of benefits?
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If yes, describe. |
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If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 3 - COOLING ASSISTANCE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
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Section 3 - Cooling Assistance |
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Eligibility, 2605(c)(1)(A), 2605 (b)(2) - Assurance 2 |
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3.1 Designate The income eligibility threshold used for the Cooling component: |
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Add |
Household size |
Eligibility Guideline |
Eligibility Threshold |
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1 |
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3.2 Do you have additional eligibility requirements for cooling assistance? |
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3.3 Check the appropriate boxes below and describe the policies for each. |
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Do you require an Assets test ? |
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If yes, describe: |
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Do you have additional/differing eligibility policies for: |
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Renters? |
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If yes, describe: |
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Renters Living in subsidized housing ? |
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If yes, describe: |
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Renters with utilities included in the rent ? |
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If yes, describe: |
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Do you give priority in eligibility to: |
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Older adults? |
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If yes, describe: |
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Individuals with a disability? |
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If yes, describe: |
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Young children? |
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If yes, describe: |
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Households with high energy burdens ? |
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If yes, describe: |
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Other? |
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If yes, describe: |
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3.4 Describe how you prioritize the provision of cooling assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc. |
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Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B) |
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3.5 Check the variables you use to determine your benefit levels. (Check all that apply): |
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![]() Other - Describe: |
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Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B) |
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3.6 Describe estimated benefit levels for the fiscal year for which this plan applies. Please note: the maximum and minimum benefits must be shown in the payment matrix. |
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Minimum Benefit |
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Maximum Benefit |
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3.7
Do you provide in-kind (e.g., fans, air conditioners) and/or
other forms of benefits?
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If yes, describe.
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If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
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Section 4: CRISIS ASSISTANCE |
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Eligibility - 2604(c), 2605(c)(1)(A) |
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4.1 Designate the income eligibility threshold used for the crisis component |
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Add |
Household size |
Eligibility Guideline |
Eligibility Threshold |
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1 |
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4.2 Provide your LIHEAP program's definition for determining a crisis. If you administer multiple crisis assistance programs (i.e. winter, summer, and/or year round), include all program definitions. |
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4.3 What constitutes a life-threatening crisis? |
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Crisis Requirement, 2604(c) |
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4.4 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? 48Hours |
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4.5 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening situations? 18Hours |
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Crisis Eligibility, 2605(c)(1)(A) |
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Winter Crisis |
Summer Crisis |
Year Round Crisis |
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4.6 Do you have additional eligibility requirements for crisis assistance? |
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4.7 Check the appropriate boxes below to indicate type(s) of assistance provided |
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Do you require an Assets test ? |
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Do you give priority in eligibility to : |
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Older adults? |
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Individuals with a disability? |
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Young Children? |
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Households with high energy burdens? |
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Other? |
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In Order to receive crisis assistance: |
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Must the household have received a shut-off notice or have a near empty tank? |
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Must the household have been shut off or have an empty tank? |
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Must the household have exhausted their regular heating benefit? |
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Must renters with heating costs included in their rent have received an eviction notice ? |
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Must heating/cooling be medically necessary? |
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Must the household have non-working heating or cooling equipment? |
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Other? |
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Do you have additional / differing eligibility policies for: |
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Renters? |
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Renters living in subsidized housing? |
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Renters with utilities included in the rent? |
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Explanations of policies for each "yes" checked above: |
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Determination of Benefits |
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4.8 How do you handle crisis situations? |
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Separate component |
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Benefit Fast Track, no separate amount of crisis funds is issued. Rather benefits are issued to crisis customers within crisis response time frames. |
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Other - Describe:
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4.9 If you have a separate component, how do you determine crisis assistance benefits? |
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Amount to resolve the crisis. |
$ |
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Other - Describe:
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Crisis Requirements, 2604(c) |
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4.10 Do you accept applications for energy crisis assistance at sites that are geographically accessible to all households in the area to be served? |
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4.11 Do you provide individuals with a disability the means to: |
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Submit applications for crisis benefits without leaving their homes? |
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Travel to the sites at which applications for crisis assistance are accepted? |
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If you answered "No" to both options in question 4.11, please explain alternative means of intake to those who are homebound or physically disabled? |
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Benefit Levels, 2605(c)(1)(B) |
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||||
4.12 Indicate the maximum benefit for each type of crisis assistance offered. |
|||||
Winter Crisis maximum benefit |
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Summer Crisis maximum benefit |
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Year-round Crisis maximum benefit |
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4.13 Do you provide in-kind (e.g. blankets, space heaters, fans) and/or other forms of benefits? |
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|||||
4.14 Do you provide for equipment repair or replacement using crisis funds? |
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|
|||||
If you answered "Yes" to question 4.14, you must complete question 4.15. |
4.15 Check appropriate boxes below to indicate type(s) of assistance provided. |
|||
|
Winter Crisis |
Summer Crisis |
Year-round Crisis |
Heating system repair |
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Heating system replacement |
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Cooling system repair |
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Cooling system replacement |
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Wood stove purchase |
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Pellet stove purchase |
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Solar panel(s) |
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Utility poles / gas line hook-ups |
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Other (Specify): |
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4.16 Do any of the utility vendors you work with enforce a moratorium on shut offs? |
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|||
If you responded "Yes" to question 4.16, you must respond to question 4.17.
4.17 Describe the terms of the moratorium and any special dispensation received by LIHEAP clients during or after the moratorium period. |
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|
|||
4.18
If you experience a natural disaster, do you intend to utilize
LIHEAP crisis funds to address disaster related crisis
situations?
|
|||
If yes, describe: |
|||
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 5 - WEATHERIZATION ASSISTANCE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
||||
Section 5: WEATHERIZATION ASSISTANCE |
||||
Eligibility, 2605(c)(1)(A), 2605(b)(2) - Assurance 2 |
||||
5.1 Designate the income eligibility threshold used for the Weatherization component |
||||
Add |
Household Size |
Eligibility Guideline |
Eligibility Threshold |
|
1 |
All Household Sizes |
State Median Income |
60.00% |
|
5.2
Do
you
enter
into
an
interagency
agreement
to
have
another
government
agency
administer
a
WEATHERIZATION
component?
|
||||
5.3 If yes, name the agency and attach a copy of the Internal Agreement or Contract. |
||||
5.4
Is there a separate monitoring protocol for weatherization?
|
||||
WEATHERIZATION - Types of Rules |
||||
5.5 Under what rules do you administer LIHEAP weatherization? (Check only one.) |
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||||
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||||
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||||
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||||
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||||
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||||
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||||
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||||
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||||
|
||||
Eligibility, 2605(b)(5) - Assurance 5 |
||||
5.6 Do you require an assets test? |
|
|||
5.7 Do you have additional/differing eligibility policies for : |
||||
Renters |
|
|||
Renters living in subsidized housing? |
|
|||
5.8 Do you give priority in eligibility to: |
||||
Older adults? |
|
Individuals with a disability? |
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|
Young Children? |
|
|
House holds with high energy burdens? |
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|
Other? |
|
|
If you selected "Yes" for any of the options in questions 5.6, 5.7, or 5.8, you must provide further explanation of these policies in the text field below.
|
||
Benefit Levels |
||
5.9
Do you have a maximum LIHEAP weatherization benefit/expenditure
per household?
|
||
If yes, What is the maximum: $ |
||
5.10
Do you use an Average Cost per Unit (ACPU)?
|
||
If yes, what is the maximum: $ |
||
Types of Assistance, 2605(c)(1), (B) & (D) |
||
5.11 What LIHEAP weatherization measures do you provide ? (Check all categories that apply.) |
||
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If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 6 - Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
Section 6: Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A) |
6.1 Select all outreach activities that you conduct that are designed to assure that eligible households are made aware of all LIHEAP assistance available: |
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If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 7 - Coordination, 2605(b)(4) - Assurance 4
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
|
Section 7: Coordination, 2605(b)(4) - Assurance 4 |
|
7.1 Describe how you will ensure that the LIHEAP program is coordinated with other programs available to low-income households (TANF, SSI, WAP, etc.). |
|
|
Joint application for multiple programs |
Indicate programs included: |
|
|
Intake referrals to/from other programs |
Indicate programs included: |
|
|
One - stop intake centers |
|
Other - Describe: |
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 8 - Agency Designation,, 2605(b)(6) - Assurance 6
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
|||||
Section 8: Agency Designation, 2605(b)(6) - Assurance 6 (Required for state grant recipients and the Commonwealth of Puerto Rico) |
|||||
8.1 How would you categorize the primary responsibility of your State agency? |
|||||
|
Administration Agency |
||||
|
Commerce Agency |
||||
|
Community Services Agency |
||||
|
Energy / Environment Agency |
||||
|
Housing Agency |
||||
|
State Department of Welfare Agency (administers TANF, SNAP, and/or Medicaid) |
||||
|
Economic Development Agency |
||||
|
Other - Describe: |
||||
|
|||||
Alternate Outreach and Intake, 2605(b)(15) - Assurance 15
If you selected "Welfare Agency" in question 8.1, you must complete questions 8.2, 8.3, and 8.4, as applicable. |
|||||
8.2 How do you provide alternate outreach and intake for HEATING ASSISTANCE?
|
|||||
8.3 How do you provide alternate outreach and intake for COOLING ASSISTANCE?
|
|||||
8.4 How do you provide alternate outreach and intake for CRISIS ASSISTANCE?
|
|||||
8.5 LIHEAP Component Administration. |
Heating |
Cooling |
Crisis |
Weatherization |
8.5a Who determines client eligibility? |
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|
|||
8.5b Who processes benefit payments to gas and electric vendors? |
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|
|||
8.5c who processes benefit payments to bulk fuel vendors? |
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|
|||
8.5d Who performs installation of weatherization measures? |
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|
|||
Include a current list of subrecipient(s) name, main office address (do not list P.O. Box), phone number, county(s) served, Congressional District, and UEI number |
|||||||
If any of your LIHEAP components are not centrally-administered by a state agency, you must complete questions 8.6, 8.7, 8.8, and, if applicable, 8.9. |
|||||||
8.6 What is your process for selecting local administering agencies?
|
|||||||
8.7 How many local administering agencies do you use? |
|||||||
![]() 8.8 Have you changed any local administering agencies in the last year? Yes No |
|||||||
8.9 If so, why? |
|
||||||
|
Agency was in noncompliance with grant recipient requirements for LIHEAP - |
||||||
|
Agency is under criminal investigation |
||||||
|
Added agency |
||||||
|
Agency closed |
||||||
|
Other - describe |
|
|||||
8.10
If an subrecipient is no longer providing LIHEAP, are you aware
of prior-year LIHEAP funds being mismanaged or misspent?
|
|||||||
8.10a If yes, please explain: |
|
||||||
8.10b
If you are aware, were other federal programs impacted such as
CSBG, SSBG, Head Start, TANF, and Department of Energy
Weatherization funding, etc.
|
|||||||
8.10c if yes, please explain: |
|||||||
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
|
Section 9 - Energy Suppliers,, 2605(b)(7) - Assurance 7
U U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
|||
Section 9: Energy Suppliers, 2605(b)(7) - Assurance 7 |
|||
9.1 Do you make payments directly to home energy suppliers? |
|||
Heating |
![]()
|
No |
|
Cooling |
![]()
|
No |
|
Crisis |
![]()
|
No |
|
Are there exceptions? |
![]()
|
No |
|
If yes, Describe.
|
|||
9.2 How do you notify the client of the amount of assistance paid?
|
|||
9.3 How do you assure that the home energy supplier will charge the eligible household, in the normal billing process, the difference between the actual cost of the home energy and the amount of the payment?
|
|||
9.4 How do you assure that no household receiving assistance under this title will be treated adversely because of their receipt of LIHEAP assistance?
|
|||
9.5. Do you make payments contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible households?
|
|||
If so, describe the measures unregulated vendors may take. |
|||
Attach a copy of the template state-wide vendor agreement and/or a policy that indicates local agreements must adhere to state-wide policies and assurances |
|||
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 10 - Program, Fiscal Monitoring, and Audit, 2605(b)(10) - Assurance 10
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
|
||||
Section 10: Program, Fiscal Monitoring, and Audit, 2605(b)(10) |
|
||||
10.1. How do you ensure proper fiscal accounting and tracking of funds? Be specific about tracking of grant award, tracking of expenditures, tracking vendor (benefit) refunds, fiscal reporting process, and fiscal software systems being used.
|
|
||||
10.1a Provide Definitions for the following: |
|||||
Obligation: |
|||||
Expenditures: |
|||||
Expenditure timeframe: |
|||||
Administrative costs: |
|||||
Audit Process |
|||||
10.2. Is your LIHEAP program audited annually under the Single Audit Act and OMB Circular A - 133?
|
|||||
10.2a If yes, describe your auditor selection process |
|||||
10.3. Describe any audit findings of the grant recipient (i.e. state/tribe/territory) rising to the level of a material weakness or reportable condition cited in the single audits, inspector general reviews, or other government agency reviews from the most recently audited fiscal year. |
|||||
No
Findings
|
|||||
Finding |
Type |
Brief Summary |
Resolved? |
Action Taken |
|
1 |
|
|
|
|
|
10.4. Audits of Local Administering Agencies |
|||||
What types of annual audit requirements do you have in place for local administering agencies/district offices? Select all that apply. |
|||||
|
|||||
|
|||||
|
|||||
|
|||||
Compliance Monitoring |
|||||
10.5. Describe your monitoring process for compliance at each level below. Check all that apply. |
|||||
Grant recipient employees: |
|||||
|
|||||
|
|||||
|
|||||
|
|||||
|
|||||
Local Administering Agencies / District Offices: |
|||||
|
|||||
|
|
||||
|
|
||||
|
|
||||
|
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|
|
10.6 Explain, or attach a copy of your local agency monitoring schedule and protocol. |
|
10.7. Describe how you select local agencies for monitoring reviews. Attach a risk assessment if subrecipients are utilized. . |
Site Visits: |
Desk Reviews: |
10.8. How often is each local agency monitored? Please attach a monitoring schedule if one has been developed. |
|
|
|
10.9. How many local agencies are currently on corrective action plans? |
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 11 - Timely and Meaningful Public Participation, , 2605(b)(12) - Assurance 12, 2605(c)(2)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
||
Section 11: Timely and Meaningful Public Participation, 2605(b)(12), 2605(C)(2) |
||
11.1 How did you obtain input from the public in the development of your LIHEAP plan? Select all that apply. Note: tribes do not need to hold a public hearing but must ensure participation through other means. |
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
Public Hearings, 2605(a)(2) - For States and the Commonwealth of Puerto Rico Only |
||
11.3 List the date and location(s) that you held public hearing(s) on the proposed use and distribution of your LIHEAP funds? |
||
|
Date |
Event Description |
1 |
|
|
2 |
|
|
11.4. How many parties commented on your plan at the hearing(s)? None |
||
11.5 Summarize the comments you received at the hearing(s).
|
||
11.6 What changes did you make to your LIHEAP plan as a result of public participation and solicitation of input? |
||
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 12 - Fair Hearings,2605(b)(13) - Assurance 13
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
Section 12: Fair Hearings, 2605(b)(13) - Assurance 13 |
12.1 How many fair hearings did the grant recipient have in the prior Federal fiscal year? |
12.2 How many of those fair hearings resulted in the initial decision being reversed? |
12.3 Describe any policy and/or procedural changes made in the last Federal fiscal year as a result of fair hearings? |
12.4 Describe your fair hearing procedures for households whose applications are denied and/or not acted upon in a timely manner |
12.5 When and how are applicants informed of these rights? |
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 13 - Reduction of home energy needs,2605(b)(16) - Assurance 16
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
Section 13: Reduction of home energy needs, 2605(b)(16) - Assurance 16 |
13.1 Describe how you use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and thereby the need for energy assistance? |
13.2 How do you ensure that you don't use more than 5% of your LIHEAP funds for these activities? |
13.3 Describe the impact of such activities on the number of households served in the previous Federal fiscal year? Impact can be measured in many different ways: using logic models, data tracking systems, process evaluation, impact evaluation, number of households served vs applied, and performance management for example |
13.4 Describe the level of direct benefits provided to those households in the previous Federal fiscal year. |
|
13.5 How many households received these services? |
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 14 - Leveraging Incentive Program ,2607A
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
|||
Section 14: Leveraging Incentive Program, 2607(A) |
|||
14.1 Do you plan to submit an application for the leveraging incentive program?
|
|||
14.2 Describe instructions to any third parties and/or local agencies for submitting LIHEAP leveraging resource information and retaining records. |
|||
14.3 For each type of resource and/or benefit to be leveraged in the upcoming year that will meet the requirements of 45 C.F.R. § 96. 87(d)(2)(iii), describe the following: |
|||
Resource |
What is the type of resource or benefit? |
What is the source(s) of the resource? |
How will the resource be integrated and coordinated with LIHEAP? |
1 |
|
|
|
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
|
Section 15: Training |
|
15.1 Describe the training you provide for each of the following groups: |
|
a. Grant recipient Staff: |
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|
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How often? |
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b. Local Agencies: |
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How often? |
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|
|
c. Vendors |
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|
|
How often? |
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|
|
![]() Policies are outlined in a vendor manual |
|
|
![]() 15.2 Does your training program address fraud reporting and prevention? Yes No |
|
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 16 - Performance Goals and Measures, 2605(b)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
Section 16: Performance Goals and Measures, 2605(b) - Required for States Only |
16.1 Describe your progress toward meeting the data collection and reporting requirements of the four required LIHEAP performance measures. Include timeframes and plans for meeting these requirements and what you believe will be accomplished in the coming federal fiscal year.
|
If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 17 - Program Integrity, 2605(b)(10)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised 05/92,02/95,03/96,12/98,11/01,09/23 ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No.: 0970-0075 Expiration Date: XX/XX/XXXX
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN SF - 424 - MANDATORY |
|||||||||||
Section 17: Program Integrity, 2605(b)(10) |
|||||||||||
17.1 Fraud Reporting Mechanisms |
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a. Describe all mechanisms available to the public for reporting cases of suspected waste, fraud, and abuse. Select all that apply. |
|||||||||||
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|||||||||||
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|||||||||||
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|||||||||||
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|||||||||||
b. Describe strategies in place for advertising the above-referenced resources. Select all that apply |
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|||||||||||
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|||||||||||
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17.2. Identification Documentation Requirements |
|||||||||||
a. Indicate which of the following forms of identification are required or requested to be collected from LIHEAP applicants or their household members. |
|||||||||||
Type of Identification Collected |
Collected from Whom? |
||||||||||
Applicant Only |
All Adults in Household |
All Household Members |
|||||||||
Social Security Card is photocopied and retained |
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Required |
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Required |
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Required |
|||||
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Requested |
|
Requested |
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Requested |
||||||
Social Security Number (Without actual Card) |
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Required |
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Required |
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Required |
|||||
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Requested |
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Requested |
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Requested |
||||||
Government-issued identification card (i.e.: driver's license, state ID, Tribal ID, passport, etc.) |
|
Required |
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Required |
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Required |
|||||
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Requested |
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Requested |
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Requested |
||||||
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Other |
Applicant Only Required |
Applicant Only Requested |
All Adults in Household Required |
All Adults in Household Requested |
All Household Members Required |
All Household Members Requested |
||||
1 |
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b. Describe any exceptions to the above policies. |
17.3 Identification Verification |
Describe what methods are used to verify the authenticity of identification documents provided by clients or household members. Select all that apply |
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17.4. Citizenship/Legal Residency Verification |
What are your procedures for ensuring that household members are U.S. citizens or qualified non-citizens who are qualified to receive LIHEAP benefits? Select all that apply. |
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17.5. Income Verification |
What methods does your agency utilize to verify household income? Select all that apply. |
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17.6. Protection of Privacy and Confidentiality |
Describe the financial and operating controls in place to protect client information against improper use or disclosure. Select all that apply. |
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17.7. Verifying the Authenticity |
What policies are in place for verifying vendor authenticity? Select all that apply. |
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17.8. Benefits Policy - Gas and Electric Utilities |
What policies are in place to protect against fraud when making benefit payments to gas and electric utilities on behalf of clients? Select all that apply. |
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17.9. Benefits Policy - Bulk Fuel Vendors |
What procedures are in place for averting fraud and improper payments when dealing with bulk fuel suppliers of heating oil, propane, wood, and other bulk fuel vendors? Select all that apply. |
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17.10. Investigations and Prosecutions |
Describe the Grant recipient's procedures for investigating and prosecuting reports of fraud, and any sanctions placed on clients/staff/vendors found to have committed fraud. Select all that apply. |
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If any of the above questions require further explanation or clarification that could not be made in the fields provided, attach a document with said explanation here. |
Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters |
Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary Covered Transactions
Instructions for Certification
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![]() voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.
Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary Covered Transactions
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transactions
Instructions for Certification
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![]() determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
Certification Regarding Debarment, Suspension, Ineligibility an Voluntary Exclusion--Lower Tier Covered Transactions (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. |
![]() (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
By checking this box, the prospective primary participant is providing the certification set out above. |
Section 19: Certification Regarding Drug-Free Workplace Requirements
Section 19: Certification Regarding Drug-Free Workplace Requirements |
This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central pint is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201.
Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification)
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![]() Controlled substance means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);
Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes;
Criminal drug statute means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance;
Employee means the employee of a grant recipient directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grant recipient's payroll. This definition does not include workers not on the payroll of the grant recipient (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grant recipient's payroll; or employees of subrecipients or subcontractors in covered workplaces).
Certification Regarding Drug-Free Workplace Requirements Alternate I. (Grant recipients Other Than Individuals) The grant recipient certifies that it will or will continue to provide a drug-free workplace by:,
c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a);
(e) Notifying the agency in writing, within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification |
number(s) of each affected grant; (f)Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d)(2), with respect to any employee who is so convicted -(1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). (B) The grant recipient may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant:
Place of Performance (Street address, city, county, state, zip code) |
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* Address Line 1, do not enter P.O. Box |
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Address Line 2 |
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Address Line 3 |
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* City |
* State |
* Zip Code |
Check if there are workplaces on file that are not identified here. Alternate II. (Grant recipients Who Are Individuals)
[55 FR 21690, 21702, May 25, 1990]
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Section 20: Certification Regarding Lobbying
Section 20: Certification Regarding Lobbying |
The submitter of this application certifies, to the best of his or her knowledge and belief, that:
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,’’ in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
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Assurances |
the Social Security Act;
(except that a State may not exclude a household from eligibility in a fiscal year solely on the basis of household income if such income is less than 110 percent of the poverty level for such State, but the State may give priority to those households with the highest home energy costs or needs in relation to household income.
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![]() energy-related programs under subtitle B of title VI (relating to community services block grant program), under the supplemental security income program, under part A of title IV of the Social Security Act, under title XX of the Social Security Act, under the low-income weatherization assistance program under title IV of the Energy Conservation and Production Act, or under any other provision of law which carries out programs which were administered under the Economic Opportunity Act of 1964 before the date of the enactment of this Act;
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(D) ensure that the provision of vendor payments remains at the option of the State in consultation with local grant recipients and may be contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible households, including providing for agreements between suppliers and individuals eligible for benefits under this Act that seek to reduce home energy costs, minimize the risks of home energy crisis, and encourage regular payments by individuals receiving financial assistance for home energy costs; |
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* This assurance is applicable only to States, and to territories whose annual regular LIHEAP allotments exceed $200,000. Neither territories with annual allotments of $200,000 or less nor Indian tribes/tribal organizations are subject to Assurance 15.
(16) use up to 5 percent of such funds, at its option, to provide services that encourage and enable households to reduce their home energy needs and |
thereby the need for energy assistance, including needs assessments, counseling, and assistance with energy vendors, and report to the Secretary concerning the impact of such activities on the number of households served, the level of direct benefits provided to those households, and the number of households that remain unserved. |
By checking this box, the
prospective primary participant is agreeing to the Assurances set out
above.
Plan Attachments
PLAN ATTACHMENTS |
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The following documents must be attached to this application |
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Optional: Policy Manual |
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Optional: Subrecipient contract |
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Optional: Model Plan Participation notes for Tribes |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | FY25 Model Plan Proposed Changes_Detail Form |
Author | OLDC (InForm) |
File Modified | 0000-00-00 |
File Created | 2024-07-22 |