Form 1 LIHWAP Quarterly Report

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Overview

Quarterly Q1
Quarterly Q2
Quarterly Q3
Quarterly Q4

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Sheet 1: Quarterly Q1

OMB Control No. xxxx-xxxx		Expiration Date: xx/xx/xxxx
Low Income Household Water Assistance Program Quarterly Performance and Management Form
Recipient Information
Recipient Name:
Contact Name:
Contact Phone Number:
Contact Email:
First Quarterly Performance and Management Report (October 1- December 31)
I. Total Households Assisted
	A. Total Households Q1
1. Unduplicated number of households assisted	0
II. Assistance Provided by Service Type
	Number of assisted households by Service Type
Type of LIHWAP assistance for households	A. Water or Wastewater	B. Multiple Water Services	C. Other Water Services
1. Restoration of services	0	0	0
2. Prevention of disconnection of services	0	0	0
3. Reduction of rates charged	0	0	0
*If other services were paid for with LIHWAP funds, please explain
Response:
III. LIHWAP Implementation Information
Please attach vendor list to the report, see instructions	A. Number of Water Vendors
1. Of the water vendors in your state, territory or tribe, how many vendors have you entered into an agreement with?
2. If you have not entered into a vendor agreement with all vendors, please describe the barriers to execution below.
Response:
3. Have you begun to accept applications for LIHWAP?	Yes	Date started?	No	Estimated start date for accepting applications?
4. If you have not begun to accept applications for LIHWAP, please explain why below.
Response:
5. If you have started accepting applications, have all areas of your state, territory or tribe begun implementation? If no, please briefly explain your approach/plan for getting to full implementation, including which areas have not begun accepting applications and why.
Response:
6. If applicable, have you executed agreements with all of your subrecipients? If no, please explain.
Response:
IV. Performance Management
1. Describe up to three notable accomplishments achieved by LIHWAP implementation during the reporting period. Please include a participant success story, if applicable.
Response:
2. Describe any challenges with LIHWAP implementation during the reporting period.
Response:
3. Are there additional unmet water or wastewater needs in your service area? If yes, please describe.
Response:
4. Do you have any training and/or technical assistance needs that you would like the Office of Community Services to offer support for?
Response:
V. Remarks
1. Enter any explanation needed regarding the reliability and/or validity of the above-reported data.
Response:
VI. 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:
b. Title of Authorized Official:
c. Signature of Authorized Official:
d. Date Signed:

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Sheet 2: Quarterly Q2

OMB Control No. xxxx-xxxx		Expiration Date: xx/xx/xxxx
Low Income Household Water Assistance Program Quarterly Performance and Management Form
Recipient Information
Recipient Name:
Contact Name:
Contact Phone Number:
Contact Email:
Second Quarterly Performance and Management Report (January 1- March 31)
I. Total Households Assisted
	A. Total Households Q2	B Total Cumulative Households
1. Unduplicated number of households assisted	5	5
II. Assistance Provided by Service Type
	Number of assisted households by Service Type
Type of LIHWAP assistance for households	A. Water or Wastewater	B. Multiple Water Services	C. Other Water Services
1. Restoration of services	0	0	0
2. Prevention of disconnection of services	0	0	0
3. Reduction of rates charged	0	0	0
*If other services were paid with LIHWAP funds, please explain
Response:
III. LIHWAP Implementation Information
Please attach an updated vendor list to the report, see instructions	A. Number of Water Vendors
1. Of the water vendors in your state, territory, or tribe, how many vendors have you entered into an agreement with?
2. If you have not entered into a vendor agreement with all vendors, please describe the barriers to execution below.
Response:
					Estimated start date for accepting applications?
4. If you have not begun to accept applications for LIHWAP, please explain why below.
Response:
5. If you have started accepting applications, have all areas of your state, territory or tribe begun implementation? If no, please briefly explain your approach/plan for getting to full implementation, including which areas have not begun accepting applications and why.
Response:
6. If applicable, have you executed agreements with all of your subrecipients? If no, please explain.
Response:
IV. Performance Management
1. Describe up to three notable accomplishments achieved by LIHWAP implementation during the reporting period. Please include a participant success story, if applicable.
Response:
2. Describe any challenges with LIHWAP implementation during the reporting period.
Response:
3. Are there additional unmet water and wastewater needs in your service area? If yes, please describe.
Response:
4. Do you have any training and/or technical assistance needs that you would like the Office of Community Services to offer support for?
Response:
V. Remarks
1. Enter any explanation needed regarding the reliability and/or validity of the above-reported data.
Response:
VI. 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:
b. Title of Authorized Official:
c. Signature of Authorized Official:
d. Date Signed:

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Sheet 3: Quarterly Q3

OMB Control No. xxxx-xxxx		Expiration Date: xx/xx/xxxx
Low Income Household Water Assistance Program Quarterly Performance and Management Form
Recipient Information
Recipient Name:
Contact Name:
Contact Phone Number:
Contact Email:
Third Quarterly Performance and Management Report (April 1 - June 30)
I. Total Households Assisted
	A. Total Households Q3	B. Total Cumulative Households
1. Unduplicated number of households assisted		5
II. Assistance Provided by Service Type
	Number of assisted households by Service Type
Type of LIHWAP assistance for households	A. Water or Wastewater	B. Multiple Water Services	C. Other Water Services
1. Restoration of services	0	0	0
2. Prevention of disconnection of services	0	0	0
3. Reduction of rates charged	0	0	0
Response:
III. LIHWAP Implementation Information
Please attach an updated vendor list to the report, see instructions
1. Are there any changes in your agreements with water vendors from the previous quarters? Please explain any changes below.	Yes	No
Response:
					No
Response:
3. If applicable, have you executed agreements with all of your subrecipient? If no, please explain.
Response:
IV. Performance Management
1. Describe up to three notable accomplishments achieved by LIHWAP implementation during the reporting period. Please include a participant success story, if applicable.
Response:
2. Describe any challenges with LIHWAP implementation during the reporting period.
Response:
3. Are there additional unmet water and wastewater needs in your service area? If yes, please describe.
Response:
4. Do you have any training and/or technical assistance needs that you would like the Office of Community Services to offer support for?
Response:
V. Remarks
1. Enter any explanation needed regarding the reliability and/or validity of the above-reported data.
Response:
VI. 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:
b. Title of Authorized Official:
c. Signature of Authorized Official:
d. Date Signed:

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Sheet 4: Quarterly Q4

OMB Control No. xxxx-xxxx		Expiration Date: xx/xx/xxxx
Low Income Household Water Assistance Program Quarterly Performance and Management Form
Recipient Information
Recipient Name:
Contact Name:
Contact Phone Number:
Contact Email:
Fourth Quarterly Performance and Management Report (July 1 - September 30)
I. Total Households Assisted
	A. Total Households Q4	B. Total Cumulative Households
1. Unduplicated number of households assisted		10
II. Assistance Provided by Service Type
	Number of assisted households by Service Type
Type of LIHWAP assistance for households	A. Water or Wastewater	B. Multiple Water Services	C. Other Water Services
1. Restoration of services	0	0	0
2. Prevention of disconnection of services	0	0	0
3. Reduction of rates charged	0	0	0
*If other services were paid with LIHWAP funds, please explain
Response:
III. LIHWAP Implementation Information
Please attach an updated vendor list to the report, see instructions
1. Are there any changes in your agreements with water vendors from the previous quarter? Please explain any changes below.	Yes	No
Response:
					Yes	If no, please explain
3. If you are still accepting applications, are there any changes to which portions of your service area are accepting applications and implementing LIHWAP from Quarter 3? If yes, please explain the changes.	Yes	No
Response:
IV. Performance Management
1. Describe up to three notable accomplishments achieved by LIHWAP implementation during the reporting period. Please include a participant success story, if applicable.
Response:
2. Describe any challenges with LIHWAP implementation during the reporting period.
Response:
3. Are there additional unmet water and wastewater needs in your service area? If yes, please describe.
Response:
4. Do you have any training and/or technical assistance needs that you would like the Office of Community Services to offer support for?
Response:
5. Please list and describe up to three lessons learned during the first year of LIHWAP implementation.
Response:
V. Remarks
1. Enter any explanation needed regarding the reliability and/or validity of the above-reported data.
Response:
VI. 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:
b. Title of Authorized Official:
c. Signature of Authorized Official:
d. Date Signed: