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OMB No. 0970-0037 Expires XX/XXXX |
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| U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES |
| ADMINISTRATION FOR CHILDREN AND FAMILIES |
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| FORM ACF-535 |
| LOW INCOME HOME ENERGY ASSISTANCE PROGRAM |
| QUARTERLY ALLOCATION ESTIMATES |
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| Paperwork Act Notice: This information is used by the Administration for Children and Families to determine the quarterly |
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| allocation estimates for the LIHEAP program. This is public information and is published in an annual report to Congress. |
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| Reporting Burden Notice: The reporting burden imposed by this collection of information is estimated to average .25 hours |
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| per response. This includes time for reviewing instructions, searching data resources, gathering and maintaining the data needed, |
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| and completing and reviewing the information collected. |
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| Note: An Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it |
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| displays a currently valid OMB control number. |
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| STATE |
SUBMISSION (MARK BOX) |
REPORT FOR FISCAL YEAR |
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[ ] New [ ] Revised |
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| For each quarter indicated, enter the estimated percentage of the annual funding required for that quarter. |
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1 ST QUARTER:____________________% |
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2 ND QUARTER:____________________% |
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3 RD QUARTER:____________________% |
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4 TH QUARTER:____________________% |
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TOTAL:_______100__________% |
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| IF THE STATE FAILS TO SUBMIT THIS REPORT, |
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| AWARDS WILL BE ISSUED IN FOUR EQUAL AMOUNTS |
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| Signature: Approving Official |
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Typed Name, Title, Agency Name |
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| Date Submitted: |
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| Page 1 of 1 |
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| Submit Completed Reports to: |
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| Administration for Children and Families |
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| Office of Administration |
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| Office of Grants Management |
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| Division of Mandatory Grants |
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| Attn: Lydia Peele, Mail Stop: OA/OGM/DMG |
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| 370 L'Enfant Promenade, S.W. |
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| Washington, D.C. 20447 |
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| Fax: 202-401-5519 |
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| E-Mail: Lydia.Peele@acf.hhs.gov |
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