Form 1 LIHEAP GRANTEE SURVEY

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Overview

State
Survey Edit Checks

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Sheet 1: State

TIMELY RESPONSE TO QUESTIONS ON THIS SURVEY IS MANDATORY. INFORMATION WILL BE USED TO RESPOND TO CONGRESSIONAL INQUIRIES, TO CALCULATE

1

2

3

4

5

6

LIHEAP COST EFFICIENCY, AND TO PROVIDE DATA FOR THE ANNUAL LIHEAP REPORT TO CONGRESS UNDER SECTION 2610 OF PUBLIC LAW 97-35, AS AMENDED.

Block

Emergency

FFY 09 Funds

Oil

FFY 10 Leveraging

FFY 09 Leveraging

AK

Allotment

Funds

FFY 10

Funds

Awards

Obligated in FFY 10

See also LIHEAP AT-2010-13 at: www.acf.hhs.gov/programs/ocs/liheap/guidance/action_transmittals/at11-01.html

2

FOR DEA/OCS Office Use

$0

$0

$0

$0

$0

$0

LIHEAP GRANTEE SURVEY FOR FEDERAL FISCAL YEAR (FFY) 2010

SECTION I. RESPONDENT DATA:

AK

1a

1b

1c

2a

2b

2c

3

Winter Crisis Assistance

Summer Crisis Assistance

Year-round Crisis Assistance

a. Other Crisis Assistance

b. Other Crisis Assistance

c. Other Crisis Assistance

4

5

6

7

8

9

10

Respondent's Name:

Date:

Phone #:

Heating Assistance

Cooling Assistance

Total

Maximum annual

Maximum annual

Maximum annual

Maximum annual

Maximum annual

Maximum annual

Weatherization Assistance

Funds Carried

Emergency Contingency

Leveraging Funds

Funds to

Assurance

Administration/

Max annual poverty cutoff for 4-person household

Amount of

Average household

Max. annual poverty cutoff

Amount of

Average household

Max. annual poverty cutoff

Crisis

Amount of

Average household

poverty cutoff for a

Amount of

Average household

poverty cutoff for a

Amount of

Average household

poverty cutoff for a

Description

Amount of

Average household

poverty cutoff for a

Description

Amount of

Average household

poverty cutoff for a

Description

Amount of

Average household

poverty cutoff for a

Amount of

Max. annual poverty cutoff

Over to

Funds to be

to be Obligated

Develop Leveraging

16

Planning

Heating

Cooling

Winter

Summer

Year-round

a. Other

b. Other

c. Other

Wxz.

assistance

benefit

for a 4-person household

assistance

benefit

for a 4-person household

Benefits

assistance

benefit

4-person household

assistance

benefit

4-person household

assistance

benefit

4-person household

assistance

benefit

4-person household

assistance

benefit

4-person household

assistance

benefit

4-person household

assistance

for a 4-person household

FFY 2011

Obligated in FFY 2011

in FFY 2011

Activities

Activities

Costs

crisis

crisis

crisis

Crisis

Crisis

Crisis

SECTION II. ESTIMATED SOURCES OF LIHEAP FUNDS:

All OF FFY 2010 (10/1/2009 TO 9/30/2010)

(Round off to Nearest Dollar)

FOR DEA/OCS Office Use

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

Emergency furnace repair or replacement

$0

$0

$0

?

$0

$0

$0

?

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

A.

All Funds Except Leveraging Incentive Awards (Items 1-4)

1.

FFY 2010 LIHEAP Block Grant Allotment (Net of Indian Tribal Set-Asides)

$0

2.

FFY 2010 Emergency Contingency Funds (Net of Indian Tribal Set-Asides)

$0

3.

All Funds Carried Over From FFY 2009

$0

4.

Petroleum Violation Escrow (Oil Overcharge) Funds Obligated in FFY 2010

$0

B.

Leveraging Incentive Award (Item 5-6)

5.

FFY 2010 Leveraging Incentive Award

$0

6.

FFY 2009 Leveraging Incentive Award Obligated in FFY 2010

$0

C.

Estimated Total Funds Available

7.

Sum of Items 1-6. This should equal the sum in Section III, Item 11.

$0

Notes:

SECTION III. ESTIMATED USES OF LIHEAP FUNDS:

All OF FFY 2010 (10/1/2009 TO 9/30/2010)

(Round off to Nearest Dollar)

A

B

C

State:

Alaska

Total Funds/

Average

Maximum Annual Dollar

Awards

Household

Income for 4-person

Funds

Benefit

Household as of 10/1/09

(Edit Check # 1)

A.

Type of LIHEAP Assistance

1.

Heating Assistance Benefits

$0

$0

$0

2.

Cooling Assistance Benefits

$0

$0

$0

3.

Total Crisis Benefits =

Amount

$0

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BREAKDOWN OF CRISIS BENEFITS

Winter Crisis Benefits

$0

$0

$0

Summer Crisis Benefits

$0

$0

$0

Year-Round Crisis Benefits

$0

$0

$0

Other Crisis Benefits:

$0

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xxxxxxxxxxxxxxxxxxxxx

a.

Emergency furnace repair or replacement

$0

$0

$0

b.

?

$0

$0

$0

c.

?

$0

$0

$0

4.

Weatherization Assistance Benefits (Edit Check # 2)

$0

xxxxxxxxxxx

$0

B.

Other Permitted Uses of LIHEAP funds

5.

FFY 2010 Unobligated Funds (excluding funds in Item 6) Carried Over

to FFY 2011 (Edit Check # 3)

$0

xxxxxxxxxxx

xxxxxxxxxxxxxxxxxxxxx

6.

FFY 2010 allowable Unobligated Emergency Contingency Funds, not

Subject to 10% Carryover Limit, Obligated in FFY 2011

$0

xxxxxxxxxxx

xxxxxxxxxxxxxxxxxxxxx

7.

FFY 2010 Leveraging Incentive Award Obligated in FFY 2011

$0

xxxxxxxxxxx

xxxxxxxxxxxxxxxxxxxxx

8.

Amount of FFY 2010 LIHEAP Block Grant Allotment Used to Identify,

Develop & Demonstrate Leveraging Activities (Edit Check # 4)

$0

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9.

Amount for Assurance 16 Activities (Edit Check # 5)

$0

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xxxxxxxxxxxxxxxxxxxxx

10.

Amount for Administration/Planning Costs (Edit Check # 6)

$0

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xxxxxxxxxxxxxxxxxxxxx

C.

Estimated Total Uses of Funds

xxxxxxxxxxxxxxxxxxxxx

11.

Sum of Items 1-10 in Column A. This should equal sum in Section II,

Item 7 (Edit Check # 7)

$0

xxxxxxxxxxx

xxxxxxxxxxxxxxxxxxxxx

xxxxxxxxxxx indicate that no information is to be filled in for that item

Complete Survey by checking values for items 1-7 in "Survey Edit Checks" tab

Notes:

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Sheet 2: Survey Edit Checks

	LIHEAP GRANTEE SURVEY EDIT CHECKS
	Grantee:	0			FFY: 2010
	Sources of Funds
	Block	Emergency	Petroleum Violation	Obligated
	Grant	Contingency	Escrow Funds	Leveraging
	Allotment	Funds*	(PVE)	Funds
					*Note: Contingency Funds are the sum of items 2 and 3 under Sources of
	$0	$0	$0	$0	Funds minus item 6 under Uses of Funds
	Base Calculations for Sources of Funds--SUMs 1 & 2
	SUM 1 = Block grant $ + emergency contingency $ + PVE $				$0
	SUM 2 = Block grant $ + emergency contingency $ + PVE $ + obligated leveraging $				$0
Edit
Check #
1.	4-Person Household Income Cutoffs => 110% of 2009 HHS Poverty Guidelines
		Heating	Cooling	Winter Crisis	Summer Crisis	Yr. Round Crisis	a. Other Crisis	b. Other Crisis	c. Other Crisis	Weatherization
	4-Person Dollar Cutoff	$0	$0	$0	$0	$0	$0	$0	$0	$0
	HHS Poverty Guidelines	$22,050	$22,050	$22,050	$22,050	$22,050	$22,050	$22,050	$22,050	$22,050
	% of Poverty Guidelines	0%	0%	0%	0%	0%	0%	0%	0%	0%
	= or Greater Than 110%	NO	NO	NO	NO	NO	NO	NO	NO	NO
2.	Weatherization (No greater than 15% of SUM 1)				Did your State receive a 25% weatherization waiver from HHS?
					Yes	?
	Weatherization	SUM	%	At or below 15%	No	?
	Assistance	1	Weatherization/SUM 1	of SUM 1?
					Do weatherization $'s include obligated leveraging funds?
	$0	$0	#DIV/0!	#DIV/0!	Yes	?
					No	?
3.	Carryover of Unobligated Funds (No greater than 10% of SUM 1)
	Carryover to	SUM	%	At or below 10%
	Next Fiscal Year	1	Carryover/SUM 1	of SUM 1?
	$0	$0	#DIV/0!	#DIV/0!
4.	Leveraging Activities (No greater than 0.08% of SUM 1 or $35,000)
				At or below
	Leveraging	SUM	Max. of $35,000 or	$35,000 or
	Activities	1	SUM 1 *.08%	SUM 1 *.08%
	$0	$0	$35,000	YES
5.	Assurance 16 Costs (No greater than 5% of SUM 2)
	Assurance 16	SUM	%	At or below 5%
	Costs	2	Assurance 16 Costs/SUM 2	of SUM 2?
	$0	$0	#DIV/0!	#DIV/0!
6.	Administration/Planning Costs (No greater than 10% of SUM 2)
	Administration &	SUM	%	At or below 10%
	Planning Costs	2	Administration & Planning/SUM 2	of SUM 2?
	$0	$0	#DIV/0!	#DIV/0!
7.	Estimated Total Sources of Funds - Estimated Total Uses of Funds
	Total	Total	Total Sources - Total Uses	Balanced?
	Sources**	Uses**			**Note: Totals from pages 1 and 2 of the survey.
	$0	$0	$0	YES
	NOTES: