State Grantees Module 1

Low Income Home Energy Assistance Program (LIHEAP) Performance Data Form

Documents and Forms

Document Name Document Type
Form 1 State Grantees Module 1 Form
LIHEAP Performance Data Form Instructions – CLEAN.docx Instruction
LIHEAP Performance Data Form Instructions – CLEAN.docx Instruction
1 LIHEAP Performance Data ADMIN_LIHEAP_OMBSSAtt2Form_FY2021.xlsx Form
1 LIHEAP Performance Data ADMIN_LIHEAP_OMBSSAtt2Form_FY2021.xlsx Form
ADMIN_LIHEAP_LPDFPopupInstrs_FY2021.docx Popup instructions for LPDF IC Document
ADMIN_LIHEAP_LPDFPopupInstrs_FY2021.docx Popup instructions for LPDF IC Document

Information Collection (IC) Details

IC Title:	State Grantees Module 1	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	LIHEAP Performance Data	ADMIN_LIHEAP_OMBSSAtt2Form_FY2021.xlsx		Yes	Yes	Fillable Printable
Instruction			LIHEAP Performance Data Form Instructions – CLEAN.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	1,836	1,836
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Popup instructions for LPDF	ADMIN_LIHEAP_LPDFPopupInstrs_FY2021.docx	12/13/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.