Form No. ACF-119, Part 1 OMB Clearance No.: 0970-0121 Expiration Date:
12/31/2009

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

**LIHEAP LEVERAGING REPORT**

**RESOURCE/BENEFIT DESCRIPTION PAGES**

**Complete this form for each separate leveraged resource/benefit that
the grantee proposes to count for this base period. Only
resources/benefits that are provided to low income households (as
defined in 45 CFR 96.87(b)(6)) may be counted.**

Grantee:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Base period:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Month/Day/Year - Month/Day/Year

1\. Resource #\_\_\_\_\_\_\_\_\_\_\_

A. Resource/benefit name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B. Gross value of countable benefits provided by resource during this
base period: \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_

C. Amount of grantee\'s own funds used to leverage this resource (not
including

funds from grantee\'s Federal LIHEAP allotment): \$

D. Costs and charges to low income households to participate/receive
these benefits: \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E. Net value of countable benefits provided by resource during this base
period

(To calculate item E, subtract items C and D from item B):
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Type of resource: \_\_\_\_Cash \_\_\_\_Discount/waiver
\_\_\_\_In-kind contribution

If more than one type of resource is claimed: Gross value of countable
benefits provided by each type of resource:

3\. Source of resource:

4\. Brief description of resource:

5\. Brief description of benefit(s) provided to low income households by
this resource (if benefits are different from resource as described in
item 4, or if more information is needed):

6\. Geographical area in which benefits were provided:

7\. Month(s) and year(s) when benefits were provided to recipients
during this base period:

8\. Number of low income households to whom benefits were provided in
this base period: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9.  Eligibility standard(s) for low income households to whom benefits
    were provided:

> Income at or below 150% of the poverty level
>
> Income at or below 60% of State median income
>
> Other\--Specify:

Page 2 - Grantee:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Resource \# \_\_\_\_\_\_\_\_

10. Agency/agencies that administered resource/benefits:

11\. Source(s) of data used to determine value of resource/benefits, and
to determine associated costs to grantee and to recipient low income
households:

12\. Brief description of how resource/benefits\' value was quantified
and how gross value of countable benefits was calculated, and how any
offsetting costs to recipient low income households were calculated;
also, for discounts, reduced rate/price actually paid, and fair market
value:

13\. Criterion/criteria in 45 CFR 96.87(d)(2) that resource/benefits
meet (check one or two): (Criteria are summarized below. For full text,
see regulations and instructions for form.)

\_\_\_\_\_\_(i) The grantee\'s LIHEAP program had an active,
substantive, significant role in developing and/or

acquiring the resource/benefits from home energy vendor(s) through
negotiation, regulation, and/or competitive bid.

\_\_\_\_\_\_(ii) The resource/benefit(s) were distributed through
(within, as part of) the grantee\'s LIHEAP program to

> low income households eligible under the grantee\'s LIHEAP standards,
> in accordance with the LIHEAP
>
> statute and regulations and the grantee\'s LIHEAP plan.

\_\_\_\_\_\_(iii) The resource/benefit(s) were distributed to low income
households as described in the grantee\'s LIHEAP

> plan, as a supplement and/or alternative to the grantee\'s LIHEAP
> program, outside (not through, within,
>
> or as part of) the LIHEAP program. They met at least one of conditions
> A through H demonstrating that
>
> they were integrated and coordinated with the grantee\'s LIHEAP
> program.

14. If criterion (i) is checked in item 13, and resource has gross value
    of \$5,000 or more: Explanation of specific role of grantee\'s
    LIHEAP program in development and/or acquisition of
    resource/benefits, demonstrating that involvement of LIHEAP program
    was active, substantive, and significant.

15. If criterion (iii) is checked in item 13: Condition(s) under
    criterion (iii) that resource meets that demonstrate(s) resource\'s
    integration/coordination with grantee\'s LIHEAP program (check one
    or more):

> \_\_\_\_\_A \_\_\_\_\_B \_\_\_\_\_C \_\_\_\_\_D \_\_\_\_\_E
> \_\_\_\_\_F \_\_\_\_\_G \_\_\_\_\_H

16. If criterion (iii) is checked in item 13, and resource has gross
    value of \$5,000 or more: Explanation of how resource/benefits were
    integrated and coordinated with grantee\'s LIHEAP program.

Form No. ACF-119, Part 2 OMB Clearance No.: 0970-0121 Expiration Date:
12/31/2009

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

**LIHEAP LEVERAGING REPORT**

**SUMMARY PAGE**

Grantee: Base Period: Month/Day/Year - Month/Day/Year

Address:

Estimated reporting burden = 38 hours total

Name and telephone number of person(s) to contact for further
information:

**On this Summary Page, show the grand totals for all leveraged
resources that the grantee proposes to count for this base period. Items
B through E are to show the sums of the information from item 1 of the
Resource/Benefit Description Pages, Part 1 of this form.**

  -------------------- ---------------- --------------- --------------- ----------------
  A. Total number of   B. Total gross   C. Total amount D. Total        E. Net value of
  leveraged resources  value of         of grantee\'s   costs/charges   these resources/
                       countable        own funds used  to low income   benefits (To
                       benefits         to leverage     households to   calculate item
                       provided by      these resources participate/    E, subtract
                       these resources  (not including  receive these   items C and D
                       to low income    funds from      benefits        from item B.)
                       households       grantee\'s                      
                       during this base Federal LIHEAP                  
                       period           allotment)                      

                                                                        

  F. Amount of funds                                                    
  from grantee\'s                                                       
  Federal LIHEAP                                                        
  allotment used to                                                     
  identify, develop,                                                    
  and demonstrate                                                       
  leveraging programs                                                   
  during this base                                                      
  period                                                                

  G. Final net value                                                    
  of leveraged                                                          
  resources/benefits                                                    
  to be counted for                                                     
  this base period (To                                                  
  calculate item G,                                                     
  subtract item F from                                                  
  item E.)                                                              
  -------------------- ---------------- --------------- --------------- ----------------

I certify that, to the best of my knowledge, the information in this
LIHEAP Leveraging Report is correct, and documentation to support this
information is readily available and will be submitted upon request to
the U.S. Department of Health and Human Services.

Signature of Chief Executive Officer or Designee Title Date

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

**SAMPLE LEVERAGING SUMMARY WORKSHEET**

This sample format is voluntary. No penalties will be imposed if
grantees do not submit it.

Grantee: Base Period: Page of Leveraging Summary Worksheet pages
Month/Day/Year - Month/Day/Year

+----+-------------------+----------+----------+----------+----------+
| Re | A.                | B. Gross | C.       | D.       | E. Net   |
| so | Resource/benefit  | value of | Amount   | Costs    | value of |
| ur | name (Submit a    | c        | of       | /charges | r        |
| ce | Resource/Benefit  | ountable | gr       | to low   | esource/ |
|    | Description Pages | benefits | antee\'s | income   | benefits |
| \# | form for each     | provided | own      | ho       | (To      |
|    | resource/benefit  | by this  | funds    | useholds | c        |
|    | listed below.)    | resource | used to  | to       | alculate |
|    |                   | to low   | leverage | par      | item E   |
|    |                   | income   | this     | ticipate | for each |
|    |                   | ho       | resource | /receive | r        |
|    |                   | useholds | (not     | these    | esource/ |
|    |                   | during   | i        | benefits | benefit, |
|    |                   | this     | ncluding |          | subtract |
|    |                   | base     | funds    |          | items C  |
|    |                   | period   | from     |          | and D    |
|    |                   |          | gr       |          | from     |
|    |                   |          | antee\'s |          | item B   |
|    |                   |          | Federal  |          | for that |
|    |                   |          | LIHEAP   |          | r        |
|    |                   |          | al       |          | esource/ |
|    |                   |          | lotment) |          | b        |
|    |                   |          |          |          | enefit.) |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
|    |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+
| S  |                   |          |          |          |          |
| ub |                   |          |          |          |          |
| to |                   |          |          |          |          |
| ta |                   |          |          |          |          |
| ls |                   |          |          |          |          |
| f  |                   |          |          |          |          |
| or |                   |          |          |          |          |
| th |                   |          |          |          |          |
| is |                   |          |          |          |          |
| pa |                   |          |          |          |          |
| ge |                   |          |          |          |          |
+----+-------------------+----------+----------+----------+----------+