Document
Household Report - Long Form
ICR 202606-0970-007 · OMB 0970-0060 · Object 169885300.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Household Report - Long Form |
| Author | Lawson, Katina (ACF) |
| Last Modified By | Writer |
| File Modified | 2026-01-28 |
| File Created | 2026-06-17 |
| Conversion State | complete |
Extracted Text
Division of Energy Assistance Office of Community Services
Administration for Children and Families
The U.S. Department of Health and Human Services
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-LONG FORM
Grant Recipient Information
OMB Clearance No.: 0970-0060 Expiration Date:
Grantee Name:
FFY 2026 (10/01/2025 - 09/30/2026)
Contact Person:
Phone:
Email Address:
Instructions
The 50 States, District of Columbia, and the Commonwealth of Puerto Rico are required to use the LIHEAP Household Report- Long Form to provide LIHEAP recipient count information for the designated Federal Fiscal Year. The Report consists of the following nine sections in which grant recipients should include LIHEAP-assisted household and/or household member counts.
I. Number of Assisted Households
II. Number of Assisted Households by Poverty Interval
III. Number of Assisted Households by Vulnerable Population
IV. Number of Assisted Households by Young Child Age Category
V. Number of Assisted Households Owner/Renter Status
The required data for LIHEAP assisted households for each State are included in the Department's LIHEAP annual Report to Congress. The required data are also used in measuring LIHEAP targeting performance under the Government Performance and Results Act (GPRA) of 1993, as amended by the GPRA Modernization Act of 2010. As the reported data are aggregated, the information in this report is not considered to be confidential.
Do the data below include estimated figures?
If YES, select the appropriate box in column A of Section I for each type of assistance that has at least one estimated data entry.
Select One
Yes No
I. Number of assisted households
Number of assisted households
Ty pe of LIHEAP assistance
A. Select if estimated data
B. Total Number of Households
1. Heating
2. Heating (Reserved for other supplemental funding)
3. Cooling
4. Cooling (Reserved for other supplemental funding)
5. Crisis
a. Year Round
b. Year Round (Reserved for other supplemental funding)
c. Winter
d. Winter (Reserved for other supplemental funding)
e. Summer
f. Summer (Reserved for other supplemental funding)
g. Emergency Furnace Repair and Replacement
h. Emergency Furnace Repair and Replacement (Reserved for other supplemental funding)
i. Other Crisis Assistance
j. Other Crisis Assistance (Reserved for other supplemental funding)
6. Weatherization
7. Weatherization (Reserved for other supplemental funding)
8. Any ty pe of LIHEAP assistance
9. Any type of LIHEAP assistance (Reserved for other supplemental funding)
10. Bill Payment Assistance
11. Bill Payment Assistance (Reserved for other supplemental funding)
12. Nominal Payments
13. Nominal Payments (Reserved for other supplemental funding)
II. Assisted Households by Poverty Intervals for Each Ty pe of LIHEAP Assistance
Applicable HHS Poverty Guidelines, in effect at the beginning of FFY
Ty pe of LIHEAP assistance
A. Under 75% poverty
B. 75%-100%
poverty
C. 101%-125%
poverty
D. 126%-150%
poverty
E. Over 150% poverty
1. Heating
2. Heating (Reserved for other supplemental funding)
3. Cooling
4. Cooling (Reserved for other supplemental funding)
5. Crisis
a. Year Round
b. Year Round (Reserved for other supplemental funding)
c. Winter
d. Winter (Reserved for other supplemental funding)
e. Summer
f. Summer (Reserved for other supplemental funding)
g. Emergency Furnace Repair & Replacement
h. Emergency Furnace Repair and Replacement (Reserved for other supplemental funding)
i. Other Crisis Assistance
j. Other Crisis Assistance (Reserved for other supplemental funding)
6. Weatherization
7. Weatherization (Reserved for other supplemental funding)
III. Number of Assisted Households by Vulnerable Populations
At least one household member who is a member of one the following target groups
Type of LIHEAP assistance
A. 60 years or older (elderly)
B. Disabled
C. Age 5 years or under (young child)
D. Elderly, disabled, or young child
1. Heating
3. Cooling
5. Crisis
a. Year Round
c. Winter
e. Summer
g. Emergency Furnace Repair and Replacement
h. Emergency Furnace Repair and Replacement (Reserved for other supplemental funding)
i. Other Crisis Assistance
j. Other Crisis Assistance (Reserved for other supplemental funding)
6. Weatherization
8. Any type of LIHEAP assistance
9. Any type of LIHEAP assistance (Reserved for other supplemental funding)
IV. Number of Assisted Households by Young Child Age Category (Optional)
At least one member who is a member of one the following target groups
Ty pe of LIHEAP assistance
A. Age 2 years or under
B. Age 3 years through 5 years
1. Heating
3. Cooling
2. Crisis
a. Year Round
c. Winter
e. Summer
g. Emergency Furnace Repair & Replacement
i. Other Crisis Assistance
j. Other Crisis Assistance (Reserved for other supplemental funding)
3. Weatherization
V. Number of Assisted Households Owner/Renter Status
A. Owner/Renter Status Total Number of
Households
1. Own
2. Rent with utilities billed separately
3. Rent with utilities in rental fee
4. Other
5. Unknown/not reported
6. TOTAL
Remarks
Enter any explanation needed regarding the reliability and/or validity 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: