**LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)**

**DETAILED MODEL PLAN**

**PUBLIC LAW 97-35, AS AMENDED**

**FISCAL YEAR (FY) [\_\_\_\_\_\_\_\_\_\_ ]{.underline}**

**GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_ \_ ]{.underline}**

**EIN:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_]{.underline}**

**ADDRESS
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_ \_\_\_ ]{.underline}**

**[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_]{.underline}**

**[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_]{.underline}**

**NAME OF LIHEAP
COORDINATOR[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_ \_\_]{.underline}**

**EMAIL:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ ]{.underline}**

**TELEPHONE: FAX: [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ ]{.underline}**

**PLEASE CHECK ONE: TRIBE [\_\_]{.underline} STATE [\_\_]{.underline}
INSULAR AREA [\_\_\_\_\_ ]{.underline}**

**Department of Health and Human Services**

**Administration for Children and Families**

**Office of Community Services**

**Washington, DC 20447**

**August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01**

**OMB Approval No. 0970-0075**

**Expiration Date: 9/30/2011**

[THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)]{.underline}

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 in years in which the grantee is not permitted to
file an abbreviated plan. 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.

GRANTEE FFY \_\_\_\_\_\_\_\_\_\_\_\_\_

[Assurances]{.underline}

The agrees to:

(Grantee Name)

\(1\) use the funds available under this title to\--

> \(A\) 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);

\(B\) intervene in energy crisis situations;

> \(C\) provide low-cost residential weatherization and other
> cost-effective energy-related home repair; and
>
> \(D\) 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\--

\(A\) 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;

\(ii\) supplemental security income payments under title XVI of the
Social Security Act;

\(iii\) food stamps under the Food Stamp Act of 1977; or

\(iv\) 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

\(B\) households with incomes which do not exceed the greater of---

> \(i\) an amount equal to 150 percent of the poverty level for such
> State; or

\(ii\) 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;

\(6\) 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---

\(A\) the State shall, before giving such special consideration,
determine that the agency involved meets program and fiscal requirements
established by the State; and

> \(B\) 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;

\(7\) if the State chooses to pay home energy suppliers directly,
establish procedures to \--

\(A\) notify each participating household of the amount of assistance
paid on its behalf;

\(B\) 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;

\(C\) 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 grantees 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,

> \(A\) the State will not exclude households described in clause (2)(B)
> of this subsection from receiving home energy assistance benefits
> under clause (2), and
>
> \(B\) the State will treat owners and renters equitably under the
> program assisted under this title;

\(9\) provide that\--

> \(A\) 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

\(B\) 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));

\(10\) 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\");

\(11\) 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);

\(13\) 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

\(14\) cooperate with the Secretary with respect to data collecting and
reporting under section 2610.

\(15\) \* 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.

[Certification to the Assurances]{.underline}: As Chief Executive
Officer, I agree to comply with the sixteen assurances contained in
Title XXVI of the Omnibus Budget Reconciliation Act of 1981, as
amended.\* By signing these assurances, I also agree to abide by the
standard assurances on lobbying, debarment and suspension, and a
drug-free workplace.

Signature of the Tribal or Board Chairperson or Chief Executive Officer
of the State or Territory.\*\*

Signature:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Title:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Date:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

**\* Indian tribes/tribal organizations, and territories with annual
regular LIHEAP allotments of \$200,000 or less, are not subject to
assurance 15, and thus must only certify to 15 assurances.**

**\*\* If a person other than the [Chief Executive Officer]{.underline}
of the State or territory, or Tribal Chairperson or Board Chairperson of
a tribal organization, is signing the certification to the assurances,
[a letter must be submitted delegating such authority.]{.underline}
(PLEASE ATTACH DELEGATION of AUTHORITY.) The delegation must include
authority to sign the assurances, not just to administer the program.**

**\*\*\* HHS needs the EIN (Entity Identification Number) of the State,
territory or Tribal agency that is to receive the grant funds before it
can issue the grant.**

In the above assurances which are quoted from the law, \"State\" means
the 50 States, the District of Columbia, an Indian Tribe or Tribal
Organization, or a Territory; \"title\" of the Act refers to Title XXVI
of the Omnibus Budget Reconciliation Act of 1981 (OBRA), as amended, the
\"Low Income Home Energy Assistance Act\"; \"section\" means Section
2605 of OBRA; and, \"subsection\" refers to Section 2605(b) of OBRA.

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY \_\_\_\_\_\_\_

statutory

references

2605(a)

2605(b)(1) Please 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]{.underline}

(use of

funds) heating assistance
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> cooling assistance \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> crisis assistance \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> weatherization assistance
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2605(c)(l)(C) Please 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%.**

(use of

funds)

\% heating assistance

> \% cooling assistance
>
> \% crisis assistance

2605(k)(1) % weatherization assistance

> \% carryover to the following fiscal year

2605(b)(9) % administrative and planning costs

2605(b)(16) % services to reduce home energy needs

including needs assessment (assurance 16)

> \% used to develop and implement leveraging activities (limited to the
> greater of 0.08% or \$35,000 for States, the greater of 2% or \$100
> for territories, tribes and tribal organizations).
>
> **TOTAL**

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY \_\_\_\_\_\_\_\_\_\_\_

statutory

references

2605(c)(1)(C) The funds reserved for winter crisis assistance that have
not been expended by March 15 will be reprogrammed to:

(alternate use

of crisis assistance

funds) heating assistance

> cooling assistance
>
> weatherization assistance
>
> Other(specify):

Do you accept applications for energy crisis assistance at sites that
are geographically accessible to all households in the area to be
served? (This is required by the statute.)

Yes No [\_\_\_\_\_\_\_]{.underline}

2605(b)(2) What are your maximum eligibility limits?

2605(c)(1)(A) (Please check the components to which they apply.)

**Current year guidelines must be used.**

(eligibility) 150% of the poverty guidelines:

> heating cooling crisis wx [\_\_]{.underline}
>
> 125% of the poverty guidelines:
>
> heating cooling crisis wx
>
> 110% of the poverty guidelines:
>
> heating cooling crisis wx [\_]{.underline}
>
> 60% of the State\'s median income:
>
> heating cooling crisis wx
>
> Other (specify for each component)
>
> [\
> ]{.underline}
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Households automatically eligible if one person is receiving
>
> TANF, \_\_\_\_SSI, Food Stamps, Certain means-tested veterans programs
> (heating cooling crisis wx )

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_ \_ \_\_]{.underline}

statutory

references

2605(c)(1)(A) Do you have additional eligibility requirements for:

2605(b)(2) **[HEATING ASSISTANCE]{.underline}** Yes No)

(eligibility)

Do you use: [Yes]{.underline} [No]{.underline}

> Assets test? \_\_\_\_\_ \_\_\_\_\_

Do you give priority in eligibility to:

Elderly? \_\_\_\_\_ \_\_\_\_\_

Disabled? \_\_\_\_\_

Young children? \_\_\_\_\_

> Other: \_\_\_\_\_
>
> (If Yes, please describe)

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(c)(1)(A)

2605(b)(2) Do you have additional eligibility requirements for:

**[COOLING ASSISTANCE]{.underline}** ( Yes No)

(eligibility)

Do you use: [Yes]{.underline} [No]{.underline}

Assets test? **\_\_\_\_\_\_ \_\_\_\_\_\_**

Do you give priority in eligibility to:

Elderly? **\_\_\_\_\_\_ \_\_\_\_\_\_**

Disabled? **\_\_\_\_\_\_ \_\_\_\_\_\_**

Young children? **\_\_\_\_\_\_ \_\_\_\_\_\_**

> Other: **\_\_\_\_\_\_ \_\_\_\_\_\_**

(If Yes, please describe)

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY[\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2604(c)

2605(c)(1)(A) Do you have additional eligibility requirements for:

**[CRISIS ASSISTANCE]{.underline}** ( Yes No)

(eligibility)

[Yes]{.underline} [No]{.underline}

Do you use:

> Assets test? **\_\_\_\_\_\_ \_\_\_\_\_\_**
>
> Must the household have received a\
> shut-off notice or have an empty tank? **\_\_\_\_\_\_ \_\_\_\_\_\_**
>
> Must the household have exhausted\
> regular benefit? **\_\_\_\_\_\_ \_\_\_\_\_\_**
>
> Must the household have received a\
> rent eviction notice? **\_\_\_\_\_\_ \_\_\_\_\_\_**
>
> Must heating/cooling be medically\
> necessary? **\_\_\_\_\_\_ \_\_\_\_\_\_**
>
> Other (Please explain): **\_\_\_\_\_\_ \_\_\_\_\_\_**

What constitutes a crisis? (Please describe)

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(c)(1)(A) Do you have additional eligibility requirements for:
**[WEATHERIZATION]{.underline}** ( Yes No)

(eligibility)

> Do you use: [Yes]{.underline} [No]{.underline}
>
> Assets test? \_\_\_\_\_ \_\_\_\_\_
>
> Priority groups? (Please list)
>
> Are you using Department of Energy (DOE) Low Income Weatherization
> Assistance Program (LIWAP) rules to establish eligibility or to
> establish priority eligibility for households with certain
> characteristics? \_\_\_\_\_ \_\_\_\_\_
>
> If Yes, are there exceptions? \_\_\_\_\_
>
> Please list below.

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(3) Please check the outreach activities that you

2605(c)(3)(A) conduct that are designed to assure that eligible
households are made aware of all LIHEAP assistance available:

(outreach)

> provide intake service through home visits or by telephone for the
> physically infirm (i.e. elderly or disabled).
>
> 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.
>
> make mass mailing to past recipients of LIHEAP.
>
> 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.
>
> other (Please specify):

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(4) Please describe how you will assure that LIHEAP is
coordinated with similar and related programs. The description provided
applies to all components unless specifically noted.

(coordination)

2605(b)(5) The statute requires that there be no difference in the
treatment

2605(b)(2) of households eligible because of their income and those
eligible

2605(b)(8A) because they receive benefits under TANF, Food Stamps, SSI,
or certain means-tested veterans programs (\"categorically eligible\").
How do you ensure there is no difference when determining eligibility
and benefit amounts? This applies to all components unless specifically
noted below.

(benefit

levels)

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

**[HEATING COMPONENT]{.underline}**

2605(b)(5) Please check the variables you use to determine your benefit
levels (check all that apply):

(determination

of benefits)

> 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)

2605(b)(5) Describe how you will assure that the highest benefits go to
households

2605(c)(1)(B) with the lowest incomes and the highest energy costs or
needs in relation to income, taking into account family size.

(benefit Please describe benefit levels or attach a copy of your payment
matrix.

levels)

> Do you provide in-kind (e.g., blankets, space heaters) and/or other
> forms of benefits?

Yes No If Yes, please describe.

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(5) **[COOLING COMPONENT]{.underline}**

2605(c)(1)(B)

> Please check the variables you use to determine your benefit levels
> (check all that apply):

(determination

of benefits)

> 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)

2605(b)(5) Describe how you will assure that the highest

2605(c)(1)(B) benefits will go to households with the lowest

incomes and the highest energy costs or needs

(benefit in relation to income, taking into account family size. Please
describe levels) benefit levels or attach a copy of your payment matrix.

> Do you provide in-kind (e.g. fans) and/or other forms of benefits?
>
> Yes No If Yes, please describe.

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(5) **[CRISIS COMPONENT]{.underline}**

2605(c)(1)(B)

(determination

of benefits)

> How do you handle crisis situations?
>
> separate component other (please explain)
>
> If you have a separate component, how do you determine crisis
> assistance benefits?
>
> amount to resolve crisis, up to maximum
>
> other (please describe)

(benefit

> levels) Please indicate the maximum benefit for each type of crisis
> assistance offered.
>
> heating \$ maximum benefit
>
> cooling \$ maximum benefit
>
> year-round \$ maximum benefit
>
> Do you provide in-kind (e.g. blankets, space heaters, fans) and/or
> other forms of benefits?
>
> Yes No If Yes, please describe.

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(5) **WEATHERIZATION & OTHER ENERGY RELATED**

2605(c)(1) **HOME REPAIR AND IMPROVEMENTS**

\(B\) & (D)

> What LIHEAP weatherization services/materials do you provide? (Check
> all categories that apply.)

(types of Weatherization needs assessments/audits.

assistance) Caulking, insulation, storm windows, etc.

> Furnace/heating system modifications/repairs
>
> Furnace replacement
>
> Cooling efficiency mods/repairs/replacement
>
> Other (Please describe)

(benefit Do you have a maximum LIHEAP weatherization benefit/expenditure
levels) per household? Yes No

> If Yes, what is the maximum amount? \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Under what rules do you administer LIHEAP weatherization? (Check only
> one.)

(types of Entirely under LIHEAP (not DOE) rules

rules) Entirely under DOE LIWAP rules

> Mostly under LIHEAP rules with the following DOE LIWAP rule(s) where
> LIHEAP and LIWAP rules differ (Check all that apply):
>
> Weatherize buildings 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 (Please describe)
>
> Mostly under DOE LIWAP rules, with the following LIHEAP rule(s) where
> LIHEAP and LIWAP rules differ (Check all that apply.)
>
> Weatherization not subject to DOE LIWAP maximum statewide average cost
> per dwelling unit.\
> Other (Please describe.)

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_]{.underline}

2605(b)(6) The state or tribe administers LIHEAP through the following
local agencies:

\_\_\_\_\_ county welfare offices

> \_\_\_\_\_ community action agencies (weatherization component only)
>
> \_\_\_\_\_ community action agencies (heating, cooling or crisis
>
> (agency \_\_\_\_\_ charitable organizations
>
> designation) \_\_\_\_\_ not applicable (i.e. state energy office)
>
> \_\_\_\_\_ tribal office
>
> \_\_\_\_\_ other, describe:

Have you changed local administering agencies from last year?

Yes No

> If Yes, please describe how you selected them.
>
> What components are affected by the change?

2605(c)(1)(E) Please describe any additional steps (other than those
described elsewhere in this plan) that will be taken to target
assistance to households with high home energy burdens. **(This applies
to all components. If all steps to target households with high home
energy burdens are described elsewhere in the plan, no further
information is required here.)**

(targeting of

assistance)

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(7) Do you make payments directly to home energy suppliers?

(energy

suppliers) Heating Yes No

> Cooling Yes No
>
> Crisis Yes No
>
> If Yes, are there exceptions? Yes No
>
> If Yes, please describe.

2605(b)(7)(A) If you make payments directly to home energy suppliers,
how do you notify the client of the amount of assistance paid? (Please
describe)

2605(b)(7)

\(B\) & (C)

> How do you make sure the home energy supplier performs what is
> required in this assurance? If vendor agreements are used, they may be
> attached. Indicate each component for which this description applies.

GRANTEE[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(8)(B) Is there any difference in the way owners and renters are
treated? If Yes, please describe.

(owners **[HEATING ASSISTANCE]{.underline}**

and

renters) Yes No

> **[COOLING ASSISTANCE]{.underline}**
>
> Yes No
>
> **[CRISIS ASSISTANCE]{.underline}**
>
> Yes No
>
> **[WEATHERIZATION]{.underline}**
>
> Yes No

GRANTEE[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(10) How do you ensure good fiscal accounting and tracking of
LIHEAP funds? (Please describe. Include a description of how you monitor
fiscal activities.)

(program,

fiscal

monitoring,

and audit)

> How do you monitor program activities? (Please be sure to include a
> description of how you monitor eligibility and benefit determination.)
>
> How is your LIHEAP program audited?
>
> Under the Single Audit Act? Yes No
>
> If not, please describe:
>
> For States and Territories:
>
> Is there an annual audit of local administering agencies? Yes No
>
> If not, please explain.

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(12) How did you get timely and meaningful public participation
in the development of the plan? (Please describe.)

(timely and

meaningful

public

partici-

pation)

2605(a)(2) Did you conduct public hearings on the proposed use and
distribution of your LIHEAP funds? When and where?

> \_\_\_\_\_Yes \_\_\_\_No
>
> **(Not required for Tribes and tribal organizations)**

(public

hearings)

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(13) Describe your fair hearing procedures for households whose
applications are denied or not acted on in a timely manner. When are
applicants informed of these rights?

(fair

hearings)

[Denials]{.underline}

[Applications Not Acted On In a Timely Manner]{.underline}

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(15) **For States and Puerto Rico only** (not applicable to
Tribes and tribal organizations, or to territories whose annual regular
LIHEAP allotments are \$200,000 or less):

> Does the State agency that administers the following LIHEAP component
> also administer the State\'s welfare program?

(alternate

outreach

and intake) **HEATING ASSISTANCE**

> Yes No
>
> If Yes, describe alternate process for outreach and intake:
>
> **COOLING ASSISTANCE**
>
> Yes No
>
> If Yes, describe alternate process for outreach and intake:
>
> **CRISIS ASSISTANCE**
>
> Yes No
>
> If Yes, describe alternate process for outreach and intake:

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b)(16) Do 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? (This assurance refers to activities such as
needs assessments, counseling, and assistance with energy vendors.)

> Yes No
>
> If Yes, please describe these activities.
>
> If Yes, how do you ensure that you don\'t use more than 5% (statutory
> ceiling) of your LIHEAP funds for these activities?

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2607A Please describe leveraging activities planned for the fiscal year.
**(This entry is optional.\*)** Complete this entry if you plan to apply
for

(leveraging) LIHEAP leveraging incentive funds and to include in your
leveraging report resources/benefits provided to low income households
this fiscal year under criterion (iii) in 45 CFR 96.87(d)(2). Provide
the following information for each:

> \(1\) Identify and described each resource/benefit;
>
> \(2\) Identify the source(s) of each resource; and
>
> \(3\) Describe the integration/coordination of each resource/benefit
> with the LIHEAP program, consistent with 1 or more of conditions A-H
> in 45 CFR 96.87(d)(2)(iii).

\* Leveraged resources/benefits that are counted under criterion (iii)
in 45 CFR 96.87(d)(2) must be identified and described in the grantee\'s
LIHEAP plan and distributed as indicated in the plan. In addition,
leveraging resources/benefits that are counted under criterion (ii) must
be carried out under one or more components of the grantee\'s regular
LIHEAP program.

GRANTEE
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
FFY [\_\_\_\_\_\_\_\_]{.underline}

statutory

references

2605(b) Please describe performance goals and measures planned for the
fiscal year. **(This entry is optional.)**

(performance)

goals and

measures)

**ADDITIONAL CERTIFICATIONS AND REQUIREMENTS**

Attached are additional certifications required as follows:

**\*** [**Lobbying
certification**](http://www.acf.hhs.gov/programs/ofs/grants/lobby.htm),
which must be filed by all States and territories. If applicable, Form
LLL, which discloses lobbying payments, must be submitted. **(Tribes and
tribal organizations are EXEMPT.)**

**\*** [**Debarment and suspension
certification**](http://www.acf.hhs.gov/programs/ofs/grants/drugfree.htm),
which must be filed by all grantees.

**\*** [**Drug-free workplace requirement
certification**](http://www.acf.hhs.gov/programs/ofs/grants/debar.htm),
which must be filed by all grantees, unless the grantee has filed a
statewide certification with the Department of Health and Human
Services. **STATES ONLY:** If you have filed a statewide certification
for the drug-free workplace requirement, please check here:

**\*** One of the requirements included in the 1994 reauthorization of
the statute is that state grantees must include in their annual
application for funds a report on the number and income levels of
households applying for and receiving LIHEAP assistance, and on the
number of recipient households that have members who are elderly,
disabled, or young children.

**All Tribes and those territories with allotments of less than
\$200,000** need only submit data on the number of households served by
each component (heating, cooling, weatherization and crisis). The
approval for the collection of information contained in the **LIHEAP
Household Report** is covered by OMB approval number 0970-0060.

**\*** Though not a part of this application, the report on funds to be
carried over or available for reallotment as required by section 2607(a)
for the preceding year must be submitted by August 1 of each year. A
grant award for the current fiscal year may not be made until the
carryover/reallotment report is received. The approval for the
collection of information contained in the **LIHEAP Carryover and
Reallotment** **Report** is covered by OMB approval number 0970-0106.