LIHEAP Detailed Model Plan Application - FY26

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
* 1.a. Type of Submission: Plan			* 1.b. Frequency: Annual			* 1.c. Consolidated Application/ Plan/Funding Request? Explanation:				* 1.d. Version: Initial Resubmission Revision Update
						2. Date Received:				State Use Only:
						3. Applicant Identifier:
						4a. Unique Entity Identifier (UEI)				5. Date Received By State:
						4b. Federal Award Identifier:				6. State Application Identifier:
7. APPLICANT INFORMATION
* a. Legal Name:
* b. Address:
* Street 1:						Street 2:
* City:						County:
* State:						Province:
* Country:						* Zip / Postal Code:
c. Organizational Unit:
Department Name:						Division Name:
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):
	* First Name:								* Last Name:
	Title:				Organizational Affiliation:
* Telephone Number:	Fax Number				* Email:
* 8. TYPE OF APPLICANT:
a. Is the applicant and Tribal Consortium if yes, please attach at least one of the following documentation: Current State-Tribe agreement between their state and the Consortium, signed by the State Chief Executive Officer (such as the Governor or the delegate) and the Consortium President; Consortium letter listing the tribes and signed by the elected Tribal Chief or President of each tribe in the Consortium and signed by the Consortium President; A current resolution letter from each tribe in the Consortium, signed by the elected Tribal Chief or President of that tribe. Each resolution letter needs to state that the Consortium has the tribes’ permission to apply for, and administer, LIHEAP on their behalf; needs to designate a time period for the permission or until rescinded or revoked.
				Catalog of Federal Domestic Assistance Number:			CFDA Title:
9. CFDA Numbers and Titles
10. Descriptive Title of Applicant's Project
11. Areas Affected by Funding:
12. CONGRESSIONAL DISTRICTS OF APPLICANT:

13. FUNDING PERIOD:
a. Start Date:	b. End Date:
* 14. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?
a. This submission was made available to the State under the Executive Order 12372
Process for Review on :
b. Program is subject to E.O. 12372 but has not been selected by State for review.
c. Program is not covered by E.O. 12372.
* 15. Is The Applicant Delinquent On Any Federal Debt? YES NO
If yes, explain:
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
** 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.
17a. Typed or Printed Name and Title of Authorized Certifying Official			17c. Telephone (area code, number and extension)
			17d. Email Address
17b. Signature of Authorized Certifying Official			17e. Date Report Submitted (Month, Day, Year)
Attach supporting documents as specified in agency instructions.

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
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.
Section 1 Program Components Program Components, 2605(a), 2605(b)(1) - Assurance 1, 2605(c)(1)(C)
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
		Start Date	End Date
	Heating assistance
	Cooling assistance
	Weatherization assistance
	Summer Crisis Assistance
	Winter Crisis Assistance
	Year round crisis assistance
Provide further explanation for the dates of operation, if necessary
Estimated Funding Allocation, 2604(C), 2605(k)(1), 2605(b)(9), 2605(b)(16) - Assurances 9 and 16
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)
Heating assistance
Cooling assistance
Summer crisis assistance
Winter crisis assistance
Year round crisis assistance
Weatherization assistance
Carryover to the following federal fiscal year
Administrative and planning costs
Services to reduce home energy needs including needs assessment (Assurance 16)
Used to develop and implement leveraging activities
TOTAL
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)

1.3 The funds reserved for winter crisis assistance that have not been expended by March 15 will be reprogrammed to:

Heating assistance

Cooling assistance

Weatherization assistance

Other (specify:)

Categorical Eligibility, 2605(b)(2)(A) - Assurance 2, 2605(c)(1)(A), 2605(b)(8A) - Assurance 8

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? Yes No

If you answered "Yes" to question 1.4, you must complete the table below and answer questions 1.5 and 1.6.

Heating

Cooling

Crisis

Weatherization

TANF

Yes No

Yes No

Yes No

Yes No

SSI

Yes No

Yes No

Yes No

Yes No

SNAP

Yes No

Yes No

Yes No

Yes No

Means-tested Veterans Programs

Yes No

Yes No

Yes No

Yes No

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.

1.5 Do you automatically enroll households without a direct annual application? Yes No

If Yes, explain:

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?

SNAP Nominal Payments

1.7a Do you allocate LIHEAP funds toward a nominal payment for SNAP households? Yes No

If you answered "Yes" to question 1.7a, you must provide a response to questions 1.7b, 1.7c, and 1.7d.

1.7b Amount of Nominal Assistance: $0.00

1.7c Frequency of Assistance

Once Per Year

Once every five years

Other - Describe:

1.7d How do you confirm that the household receiving a nominal payment has an energy cost or need?

Determination of Eligibility - Countable Income

1.8. In determining a household's income eligibility for LIHEAP, do you use gross income or net income ?

Gross Income

Net Income

Other – Describe:

1.9. Select all the applicable forms of countable income used to determine a household's income eligibility for LIHEAP

Wages

Self - Employment Income

Contract Income

Payments from mortgage or Sales Contracts

Unemployment insurance

Strike Pay

Social Security Administration (SSA ) benefits

Including Medicare deduction

Excluding Medicare deduction

Supplemental Security Income (SSI )

Retirement / pension benefits

General Assistance benefits

Temporary Assistance for Needy Families (TANF) benefits

Loans that need to be repaid

Cash gifts

Savings account balance

One-time lump-sum payments, such as rebates/credits, winnings from lotteries, refund deposits, etc.

Jury duty compensation

Rental income

Income from employment through Workforce Investment Act (WIA)

Income from work study programs

Alimony

Child support

Interest, dividends, or royalties

Commissions

Legal settlements

Insurance payments made directly to the insured

Insurance payments made specifically for the repayment of a bill, debt, or estimate

Veterans Administration (VA) benefits

Earned income of a child under the age of 18

Balance of retirement, pension, or annuity accounts where funds cannot be withdrawn without a penalty.

Income tax refunds

Stipends from senior companion programs, such as VISTA

Funds received by household for the care of a foster child

Ameri-Corp Program payments for living allowances, earnings, and in-kind aid

Reimbursements (for mileage, gas, lodging, meals, etc.)

Other

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.

1.10 Do you have an online application process Yes No

1.10a If yes, describe the type of online application (select all boxes that apply

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.

A state-wide online application that allows a customer to complete data entry and submit an application electronically for processing

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

Online application that is also mobile friendly

Other, please describe

Please include a link to a state-wide application, if available:

1.10b Can all program components be applied for online? Yes No

If no, explain which components can and cannot be applied for online:

1.11 Do you have a process for conducting and completing applications by phone: Yes No

1.12 Do you or any of your subrecipients require in person appointments in order to apply? Yes No

If yes, please provide more information regarding why in-person appointments are required and in what circumstances they are required.

1.13 How can applicants submit documentation for verification? Select all that apply:

In-person

Mail

Email

Portal application

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
Section 2 - Heating Assistance
Eligibility, 2605(b)(2) - Assurance 2
2.1 Designate the income eligibility threshold used for the heating component:
Add	Household size		Eligibility Guideline	Eligibility Threshold
2.2 Do you have additional eligibility requirements for heating assistance?		Yes No
2.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test ?		Yes No
If yes, describe:
Do you have additional/differing eligibility policies for:
Renters?		Yes No
If yes, describe:
Renters Living in subsidized housing ?		Yes No
If yes, describe:
Renters with utilities included in the rent ?		Yes No
If yes, describe:
Do you give priority in eligibility to:
Older adults?		Yes No
If yes, describe:
Individuals with a disability?		Yes No
If yes, describe:
Young children?		Yes No
If yes, describe:
Households with high energy burdens ?		Yes No
If yes, describe:
Other?		Yes No
If yes, describe:
Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
2.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.
2.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Individual bill
Dwelling type
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:
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.
Minimum Benefit		Maximum Benefit
2.7 Do you provide in-kind (e.g., blankets, space heaters) and/or other forms of benefits? Yes No
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 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
Section 3 - Cooling Assistance
Eligibility, 2605(c)(1)(A), 2605 (b)(2) - Assurance 2
3.1 Designate The income eligibility threshold used for the Cooling component:
Add	Household size		Eligibility Guideline	Eligibility Threshold
1
3.2 Do you have additional eligibility requirements for cooling assistance?		Yes No
3.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test ?		Yes No
If yes, describe:
Do you have additional/differing eligibility policies for:
Renters?		Yes No
If yes, describe:
Renters Living in subsidized housing ?		Yes No
If yes, describe:
Renters with utilities included in the rent ?		Yes No
If yes, describe:
Do you give priority in eligibility to:
Older adults?		Yes No
If yes, describe:
Individuals with a disability?		Yes No
If yes, describe:
Young children?		Yes No
If yes, describe:
Households with high energy burdens ?		Yes No
If yes, describe:
Other?		Yes No
If yes, describe:
3.4 Describe how you prioritize the provision of cooling assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.
Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
3.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Individual bill
Dwelling type
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:

Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
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.
Minimum Benefit		Maximum Benefit
3.7 Do you provide in-kind (e.g., fans, air conditioners) and/or other forms of benefits? Yes No
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 4 - CRISIS 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 4: CRISIS ASSISTANCE
Eligibility - 2604(c), 2605(c)(1)(A)
4.1 Designate the income eligibility threshold used for the crisis component
Add	Household size	Eligibility Guideline					Eligibility Threshold
1
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.
4.3 What constitutes a life-threatening crisis?
Crisis Requirement, 2604(c)
4.4 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? 48Hours
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
Crisis Eligibility, 2605(c)(1)(A)
				Winter Crisis		Summer Crisis		Year Round Crisis
4.6 Do you have additional eligibility requirements for crisis assistance?
4.7 Check the appropriate boxes below to indicate type(s) of assistance provided
Do you require an Assets test ?
Do you give priority in eligibility to :
Older adults?
Individuals with a disability?
Young Children?
Households with high energy burdens?
Other?
In Order to receive crisis assistance:
Must the household have received a shut-off notice or have a near empty tank?
Must the household have been shut off or have an empty tank?
Must the household have exhausted their regular heating benefit?
Must renters with heating costs included in their rent have received an eviction notice ?
Must heating/cooling be medically necessary?
Must the household have non-working heating or cooling equipment?
Other?
Do you have additional / differing eligibility policies for:
Renters?

Renters living in subsidized housing?
Renters with utilities included in the rent?
Explanations of policies for each "yes" checked above:
Determination of Benefits
4.8 How do you handle crisis situations?
	Separate component
	Benefit Fast Track, no separate amount of crisis funds is issued. Rather benefits are issued to crisis customers within crisis response time frames.
	Other - Describe:
4.9 If you have a separate component, how do you determine crisis assistance benefits?
	Amount to resolve the crisis.	$
	Other - Describe:
Crisis Requirements, 2604(c)
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?
Yes No Explain.
4.11 Do you provide individuals with a disability the means to:
Submit applications for crisis benefits without leaving their homes?
Yes No If No, explain.
Travel to the sites at which applications for crisis assistance are accepted?
Yes No If No, explain.
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?
Benefit Levels, 2605(c)(1)(B)
4.12 Indicate the maximum benefit for each type of crisis assistance offered.
Winter Crisis maximum benefit
Summer Crisis maximum benefit
Year-round Crisis maximum benefit
4.13 Do you provide in-kind (e.g. blankets, space heaters, fans) and/or other forms of benefits?
Yes No If yes, Describe
4.14 Do you provide for equipment repair or replacement using crisis funds?
Yes No
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
Heating system replacement
Cooling system repair
Cooling system replacement
Wood stove purchase
Pellet stove purchase
Solar panel(s)
Utility poles / gas line hook-ups
Other (Specify):
4.16 Do any of the utility vendors you work with enforce a moratorium on shut offs?
Yes No
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.
4.18 If you experience a natural disaster, do you intend to utilize LIHEAP crisis funds to address disaster related crisis situations? Yes No
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? Yes No
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? Yes No
WEATHERIZATION - Types of Rules
5.5 Under what rules do you administer LIHEAP weatherization? (Check only one.)
Entirely under LIHEAP (not DOE) rules
Entirely under DOE WAP (not LIHEAP) rules
Mostly under LIHEAP rules with the following DOE WAP rule(s) where LIHEAP and WAP rules differ (Check all that apply):
Income Threshold
Weatherization of entire multi-family housing structure is permitted if at least 66% of units (50% in 2- & 4-unit buildings) are eligible units or will become eligible within 180 days
Weatherize shelters temporarily housing primarily low income persons (excluding nursing homes, prisons, and similar institutional care facilities).
Other - Describe:
Mostly under DOE WAP rules, with the following LIHEAP rule(s) where LIHEAP and WAP rules differ (Check all that apply.)
Income Threshold
Weatherization not subject to DOE WAP maximum statewide average cost per dwelling unit.
Weatherization measures are not subject to DOE Savings to Investment Ration (SIR ) standards.
Other - Describe:
Eligibility, 2605(b)(5) - Assurance 5
5.6 Do you require an assets test?		Yes No
5.7 Do you have additional/differing eligibility policies for :
Renters		Yes No
Renters living in subsidized housing?		Yes No
5.8 Do you give priority in eligibility to:
Older adults?		Yes No

Individuals with a disability?	Yes No
Young Children?	Yes No
House holds with high energy burdens?	Yes No
Other?	Yes No
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? Yes No
If yes, What is the maximum: $
5.10 Do you use an Average Cost per Unit (ACPU)? Yes No
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.)
Weatherization needs assessments/audits		Energy related roof repair
Caulking and insulation		Major appliance Repairs
Storm windows		Major appliance replacement
Furnace/heating system modifications/ repairs		Windows/sliding glass doors
Furnace replacement		Doors
Cooling system modifications/ repairs		Water Heater
Water conservation measures		Cooling system replacement
Compact florescent light bulbs		Other - Describe:
Roof top solar		Community Solar projects
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:

Place posters/flyers in local and county social service offices, offices of aging, Social Security offices, VA, etc.

Publish articles in local newspapers or broadcast media announcements.

Include inserts in energy vendor billings to inform individuals of the availability of all types of LIHEAP assistance.

Mass mailing(s) to prior-year LIHEAP recipients.

Inform low income applicants of the availability of all types of LIHEAP assistance at application intake for other low-income programs.

Execute interagency agreements with other low-income program offices to perform outreach to target groups.

Web posting

Email

Texting

Events

Social Media

Other (specify):

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?
8.5b Who processes benefit payments to gas and electric vendors?
8.5c who processes benefit payments to bulk fuel vendors?
8.5d Who performs installation of weatherization measures?
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? Yes No
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. Yes No
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	Yes	No
Cooling	Yes	No
Crisis	Y es	No
Are there exceptions?	Yes	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? Yes No
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? Yes No
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.
Local agencies/district offices are required to have an annual audit in compliance with Single Audit Act and OMB Circular A-133
Local agencies/district offices are required to have an annual audit (other than A-133)
Local agencies/district offices' A-133 or other independent audits are reviewed by Grant recipient as part of compliance process.
Grant recipient conducts fiscal and program monitoring of local agencies/district offices
Compliance Monitoring
10.5. Describe your monitoring process for compliance at each level below. Check all that apply.
Grant recipient employees:
Internal program review
Departmental oversight
Secondary review of invoices and payments
Other program review mechanisms are in place. Describe:
Local Administering Agencies / District Offices:
On - site evaluation
Annual program review
Monitoring through central database
Desk reviews
Client File Testing / Sampling

Other program review mechanisms are in place. Describe:

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.

Annually

Bi-annually

Tri-annually

Other, when

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.
Tribal Council meeting(s)
Public Hearing(s)
Draft Plan posted to website and available for comment
Hard copy of plan is available for public view and comment
Comments from applicants are recorded
Request for comments on draft Plan is advertised
Stakeholder consultation meeting(s)
Comments are solicited during outreach activities
Other - Describe:
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? Yes No
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.

Section 15 - Training

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:
Formal training provided virtually, on-site, and/or formal training conference
How often?
Annually
Biannually
As needed
Other - Describe:
Employees are provided with policy manual
Other-Describe:
b. Local Agencies:
Formal training provided virtually, on-site, and/or formal training conference
How often?
Annually
Biannually
As needed
Other - Describe:
c. Vendors
Formal training provided virtually, on-site, and/or formal training conference
How often?
Annually
Biannually
As needed
Other - Describe:
Policies communicated through vendor agreements
Policies are outlined in a vendor manual

Other - Describe:
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
a. Describe all mechanisms available to the public for reporting cases of suspected waste, fraud, and abuse. Select all that apply.
Online Fraud Reporting
Dedicated Fraud Reporting Hotline
Report directly to local agency/district office or Grant recipient office
Report to State Inspector General or Attorney General
Forms and procedures in place for local agencies/district offices and vendors to report fraud, waste, and abuse
Posted in local adminstering agencies offices
Other - Describe:
b. Describe strategies in place for advertising the above-referenced resources. Select all that apply
Printed outreach materials
Addressed on LIHEAP application
Website
Other - Describe: 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			Required			Required				Required
			Requested			Requested				Requested
Social Security Number (Without actual Card)			Required			Required				Required
			Requested			Requested				Requested
Government-issued identification card (i.e.: driver's license, state ID, Tribal ID, passport, etc.)			Required			Required				Required
			Requested			Requested				Requested
	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

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

Verify SSNs with Social Security Administration

Match SSNs with death records from Social Security Administration or state agency

Match SSNs with state eligibility/case management system (e.g., SNAP, TANF)

Match with state Department of Labor system

Match with state and/or federal corrections system

Match with state child support system

Verification using private software (e.g., The Work Number)

In-person certification by staff (for tribal grant recipients only)

Match SSN/Tribal ID number with tribal database or enrollment records (for tribal grant recipients only)

Other - Describe:

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.

Clients sign an attestation of citizenship or U.S. Citizen or Qualified non-citizen.

Client's submission of Social Security cards is accepted as proof of U.S. Citizen or Qualified Non-Citizen.

Noncitizens must provide documentation of immigration status

Citizens must provide a copy of their birth certificate, naturalization papers, or passport

Noncitizens are verified through the SAVE system

Tribal members are verified through Tribal enrollment records/Tribal ID card

Other - Describe:

17.5. Income Verification

What methods does your agency utilize to verify household income? Select all that apply.

Require documentation of income for all adult household members

Pay stubs

Social Security award letters

Bank statements

Tax statements

Zero-income statements

Unemployment Insurance letters

Other - Describe:

Computer data matches:

Income information matched against state computer system (e.g., SNAP, TANF)

Proof of unemployment benefits verified with state Department of Labor

Social Security income verified with SSA

Utilize state directory of new hires

Other - Describe:

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.

Policy in place prohibiting release of information without written consent

Grant recipient LIHEAP database includes privacy/confidentiality safeguards

Employee training on confidentiality for:

Grant recipient employees

Local agencies/district offices

Employees must sign confidentiality agreement

Grant recipient employees

Local agencies/district offices

Physical files are stored in a secure location

Electronic files are protected in a secure location

Other - Describe:

17.7. Verifying the Authenticity

What policies are in place for verifying vendor authenticity? Select all that apply.

All vendors must register with the State/Tribe.

All vendors must supply a valid SSN or TIN/W-9 form

Vendors are verified through energy bills provided by the household

Grant recipient and/or local agencies/district offices perform physical monitoring of vendors

Other - Describe and note any exceptions to policies above:

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.

Applicants required to submit proof of physical residency

Applicants must submit current utility bill

Data exchange with utilities that verifies:

Account ownership

Consumption

Balances

Payment history

Account is properly credited with benefit

Other - Describe:

Centralized computer system/database tracks payments to all utilities

Centralized computer system automatically generates benefit level

Separation of duties between intake and payment approval

Payments coordinated among other energy assistance programs to avoid duplication of payments

Payments to utilities and invoices from utilities are reviewed for accuracy

Computer databases are periodically reviewed to verify accuracy and timeliness of payments made to utilities

Direct payment to households are made in limited cases only

Procedures are in place to require prompt refunds from utilities in cases of account closure

Vendor agreements specify requirements selected above, and provide enforcement mechanism

Other - Describe:

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.

Vendors are checked against an approved vendors list

Centralized computer system/database is used to track payments to all vendors

Clients are relied on for reports of non-delivery or partial delivery

Two-party checks are issued naming client and vendor

Direct payment to households are made in limited cases only

Vendors are only paid once they provide a delivery receipt signed by the client

Conduct monitoring of bulk fuel vendors

Bulk fuel vendors are required to submit reports to the Grant recipient

Vendor agreements specify requirements selected above, and provide enforcement mechanism

Other - Describe:

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.

Refer to state Inspector General

Refer to local prosecutor or state Attorney General

Refer to US DHHS Inspector General (including referral to OIG hotline)

Local agencies/district offices or Grant recipient conduct investigation of fraud complaints from public

Grant recipient attempts collection of improper payments. If so, describe the recoupment process

Clients found to have committed fraud are banned from LIHEAP assistance. For how long is a household banned?

Contracts with local agencies require that employees found to have committed fraud are reprimanded and/or terminated

Vendors found to have committed fraud may no longer participate in LIHEAP

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 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

1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below.

2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.

3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations.

6. The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction.

7. The prospective primary participant further agrees by submitting this proposal that it will include the clause titled ``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,'' provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or

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.

9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary Covered Transactions

1. The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency;

2. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

4. Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default.

(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

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later

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.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances.

3. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.

3. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

3. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled ``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,'' without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

3. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, 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.

3. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

3. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, 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)

1. By signing and/or submitting this application or grant agreement, the grant recipient is providing the certification set out below.

2. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grant recipient knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.

3. For grant recipients other than individuals, Alternate I applies.

4. For grant recipients who are individuals, Alternate II applies.

5. Workplaces under grants, for grant recipients other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If the grant recipient does not identify the workplaces at the time of application, or upon award, if there is no application, the grant recipient must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grant recipient's drug-free workplace requirements.

6. Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).

7. If the workplace identified to the agency changes during the performance of the grant, the grant recipient shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five).

8. Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grant recipients' attention is called, in particular, to the following definitions from these rules:

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:,

1. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grant recipient's workplace and specifying the actions that will be taken against employees for violation of such prohibition;

2. Establishing an ongoing drug-free awareness program to inform employees about --

   1. The dangers of drug abuse in the workplace;

   2. The grant recipient's policy of maintaining a drug-free workplace;

   3. Any available drug counseling, rehabilitation, and employee assistance programs; and

   4. The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

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);

4. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will --

   1. Abide by the terms of the statement; and

   2. Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction;

(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)
* Address Line 1, do not enter P.O. Box
Address Line 2
Address Line 3
* City	* State	* Zip Code
Check if there are workplaces on file that are not identified here. Alternate II. (Grant recipients Who Are Individuals) The grant recipient certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant; If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant. [55 FR 21690, 21702, May 25, 1990] By checking this box, the prospective primary participant is providing the certification set out above.

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:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated 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 Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,’’ in accordance with its instructions

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification 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 certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

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.

By checking this box, the prospective primary participant is providing the certification set out above.

Assurances

Assurances

1. use the funds available under this title to—

   1. conduct outreach activities and provide assistance to low income households in meeting their home energy costs, particularly those with the lowest incomes that pay a high proportion of household income for home energy, consistent with paragraph (5);

2. intervene in energy crisis situations;

3. provide low-cost residential weatherization and other cost-effective energy- related home repair; and

4. plan, develop, and administer the State's program under this title including leveraging programs, and the State agrees not to use such funds for any purposes other than those specified in this title;

2. make payments under this title only with respect to--

   1. households in which one or more individuals are receiving-- (i)assistance under the State program funded under part A of title IV of

the Social Security Act;

2. supplemental security income payments under title XVI of the Social Security Act;

2. food stamps under the Food Stamp Act of 1977; or

2. payments under section 415, 521, 541, or 542 of title 38, United States Code, or under section 306 of the Veterans' and Survivors' Pension Improvement Act of 1978; or

2. households with incomes which do not exceed the greater of -

1. an amount equal to 150 percent of the poverty level for such State; or

2. an amount equal to 60 percent of the State median income;

(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.

3. conduct outreach activities designed to assure that eligible households, especially households with elderly individuals or disabled individuals, or both, and households with high home energy burdens, are made aware of the assistance available under this title, and any similar energy-related assistance available under subtitle B of title VI (relating to community services block grant program) 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;

4. coordinate its activities under this title with similar and related programs administered by the Federal Government and such State, particularly low-income

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;

5. provide, in a timely manner, that the highest level of assistance will be furnished to those households which have the lowest incomes and the highest energy costs or needs in relation to income, taking into account family size, except that the State may not differentiate in implementing this section between the households described in clauses 2(A) and 2(B) of this subsection;

5. to the extent it is necessary to designate local administrative agencies in order to carry out the purposes of this title, to give special consideration, in the designation of such agencies, to any local public or private nonprofit agency which was receiving Federal funds under any low-income energy assistance program or weatherization program under the Economic Opportunity Act of 1964 or any other provision of law on the day before the date of the enactment of this Act, except that -

   1. the State shall, before giving such special consideration, determine that the agency involved meets program and fiscal requirements established by the State; and

2. if there is no such agency because of any change in the assistance furnished to programs for economically disadvantaged persons, then the State shall give special consideration in the designation of local administrative agencies to any successor agency which is operated in substantially the same manner as the predecessor agency which did receive funds for the fiscal year preceding the fiscal year for which the determination is made;

5. if the State chooses to pay home energy suppliers directly, establish procedures to --

   1. notify each participating household of the amount of assistance paid on its behalf;

2. 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 made by the State under this title;

3. assure that the home energy supplier will provide assurances that any agreement entered into with a home energy supplier under this paragraph will contain provisions to assure that no household receiving assistance under this title will be treated adversely because of such assistance under applicable provisions of State law or public regulatory requirements; and

(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;

8. provide assurances that,

   1. the State will not exclude households described in clause (2)(B) of this subsection from receiving home energy assistance benefits under clause (2), and

2. the State will treat owners and renters equitably under the program assisted under this title;

8. provide that--

   1. the State may use for planning and administering the use of funds under this title an amount not to exceed 10 percent of the funds payable to such State under this title for a fiscal year; and

2. the State will pay from non-Federal sources the remaining costs of planning and administering the program assisted under this title and will not use Federal funds for such remaining cost (except for the costs of the activities described in paragraph (16));

8. provide that such fiscal control and fund accounting procedures will be established as may be necessary to assure the proper disbursal of and accounting for Federal funds paid to the State under this title, including procedures for monitoring the assistance provided under this title, and provide that the State will comply with the provisions of chapter 75 of title 31, United States Code (commonly known as the "Single Audit Act");

9. permit and cooperate with Federal investigations undertaken in accordance with section 2608;

12. provide for timely and meaningful public participation in the development of the plan described in subsection (c);

12. provide an opportunity for a fair administrative hearing to individuals whose claims for assistance under the plan described in subsection (c) are denied or are not acted upon with reasonable promptness; and

12. cooperate with the Secretary with respect to data collecting and reporting under section 2610.

12. * beginning in fiscal year 1992, provide, in addition to such services as may be offered by State Departments of Public Welfare at the local level, outreach and intake functions for crisis situations and heating and cooling assistance that is administered by additional State and local governmental entities or community-based organizations (such as community action agencies, area agencies on aging and not-for-profit neighborhood-based organizations), and in States where such organizations do not administer functions as of September 30, 1991, preference in awarding grants or contracts for intake services shall be provided to those agencies that administer the low-income weatherization or energy crisis intervention programs.

* 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.

Section 21: Assurances

By checking this box, the prospective primary participant is agreeing to the Assurances set out above.

Plan Attachments

PLAN ATTACHMENTS
The following documents must be attached to this application
Delegation Letter is required if someone other than the Governor or Chairman Certified this Report.
Heating component benefit matrix, if applicable
Cooling component benefit matrix, if applicable
Minutes, notes, or transcripts of public hearing(s).
Optional: Policy Manual
Optional: Subrecipient contract
Optional: Model Plan Participation notes for Tribes

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