Household Report - Short Form

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OMB Clearance No.: 0970-0060 Expiration Date: 

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-SHORT FORM
Recipient Name:
FFY: 2026 (10/01/2025 - 09/30/2026)
Contact Person:


Phone:


Email Address:


The LIHEAP Household Report-Short Form is for use by all direct-grant tribes/tribal organizations.

Required Data
I. Ty pe of assistance	A. Number of assisted
households
    1. Heating
    2. Heating (Reserved for other supplemental funding)
    3. Cooling
    4. Cooling (Reserved for other supplemental funding)
    5. Winter / year-round crisis
    6. Winter / year-round crisis (Reserved for other supplemental funding)
    7. Summer crisis
    8. Summer crisis (Coronavirus Aid, Relief, and Economic Security Funding)
    9. Summer crisis (American Rescue Plan Act funding)
    10. Summer crisis (Reserved for other supplemental funding)
    11. Weatherization
    12. Weatherization (Reserved for other supplemental funding)
    21. Other crisis assistance
    22. Other crisis assistance (Reserved for other supplemental funding)
0


0


0


0

II. Number of Assisted Households Owner/Renter Status
A. Owner/Renter Status

    1. Own
    2. Rent with utilities billed separately
    3. Rent with utilities in rental fee
    4. Other
    5. Unknown/not Reported
    6. TOTAL
Total Number of Households

0


0


0


0


0


0


Remarks:

Please enter any explanation needed of the above-reported data:

Certification
Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge.
I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)
a. Name of Authorized Official:
d. Telephone:
b. Title of Authorized Official:
e. Email address:
c. Signature of Authorized Official:
f. Date Submitted: