1 Household Report Long Form

Division of Energy Assistance Office of Community Services

Administration for Children and Families

The U.S. Department of Health and Human Services

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP HOUSEHOLD REPORT-LONG FORM

Grantee Information

OMB Clearance No.: 0970-0060 Expiration Date: 03/31/2026

Grantee Name:			FFY 2024(10/01/2023 - 09/30/2024)
Contact Person:			Phone:
Email Address:

Instructions

The 50 States, District of Columbia, the Commonwealth of Puerto Rico are required to use the LIHEAP Household Report- Long Form to provide LIHEAP recipient count information for the designated Federal Fiscal Year. The Report consists of the following nine sections in which grant recipients should include LIHEAP-assisted household and/or household member counts. Number of Assisted Households Number of Assisted Households by Poverty Interval Number of Assisted Households by Vulnerable Population Number of Assisted Households by Young Child Age Category Number of Assisted Households Owner/Renter Status VI: Number of Assisted Household Applicants by Race and Ethnicity VII. Number of Assisted Household Applicants by Sex VIII: Measure: Number of Assisted Household Members by Race and Ethnicity IX: Measure: Number of Assisted Household Members by Sex The required data for LIHEAP assisted households for each State are included in the Department's LIHEAP annual Report to Congress. The required data are also used in measuring LIHEAP targeting performance under the Government Performance and Results Act (GPRA) of 1993, as amended by the GPRA Modernization Act of 2010. As the reported data are aggregated, the information in this report is not considered to be confidential.
Do the data below include estimated figures? If YES, select the appropriate box in column A of Section I for each type of assistance that has at least one estimated data entry.	Select One Yes No
I. Number of assisted households
Number of assisted households

Ty pe of LIHEAP assistance	A. Select if estimated data	B. Total Number of Households
1. Heating
2. Heating (CARES Act funding only)
3. Heating (American Rescue Plan Act funding)
4. Heating (Reserved for other supplemental funding)
5. Cooling
6. Cooling (CARES Act funding only)
7. Cooling (American Rescue Plan Act funding)
8. Cooling (Reserved for other supplemental funding)
9. Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (American Rescue Plan Act funding)
d. Year Round (Reserved for other supplemental funding)
e. Winter
f. Winter (CARES Act funding only)
g. Winter (American Rescue Plan Act funding)
h. Winter (Reserved for other supplemental funding)
i. Summer
j. Summer (CARES Act funding only)
k. Summer (American Rescue Plan Act funding)
l. Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair and Replacement
n. Emergency Furnace Repair and Replacement (CARES Act funding only)
o. Emergency Furnace Repair and Replacement (American Rescue Plan Act funding)
p. Emergency Furnace Repair and Replacement (Reserved for other supplemental funding)
q. Other Crisis Assistance
r. Other Crisis Assistance (CARES Act funding only) s. Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance ( Reserved for other supplemental funding)
10. Weatherization
11. Weatherization (CARES Act funding only)
12. Weatherization (American Rescue Plan Act funding)
13. Weatherization (Reserved for other supplemental funding)
14. Any ty pe of LIHEAP assistance
15. Any type of LIHEAP assistance (CARES Act funding only)
16. Any type of LIHEAP assistance (American Rescue Plan Act funding)
17. Any type of LIHEAP assistance (Reserved for other supplemental funding)
18. Bill Payment Assistance
19. Bill Payment Assistance (CARES Act funding only)
20. Bill Payment Assistance (American Rescue Plan Act funding)
21. Bill Payment Assistance (Reserved for other supplemental funding)
22. Nominal Payments
23. Nominal Payments (CARES Act funding only)
24. Nominal Payments (American Rescue Plan Act funding)

25. Nominal Payments (Reserved for other supplemental funding)
II. Assisted Households by Poverty Intervals for Each Ty pe of LIHEAP Assistance
Applicable HHS Poverty Guidelines, in effect at the beginning of FFY
Ty pe of LIHEAP assistance	A. Under 75% poverty	B. 75%-100% poverty	C. 101%-125% poverty	D. 126%-150% poverty		E. Over 150% poverty
1. Heating
2. Heating (CARES Act funding only)
3. Heating (American Rescue Plan Act funding)
4. Heating (Reserved for other supplemental funding)
5. Cooling
6. Cooling (CARES Act funding only)
7. Cooling (American Rescue Plan Act funding)
8. Cooling (Reserved for other supplemental funding)
9. Crisis
a. Year Round
b. Year Round (CARES Act funding only)
c. Year Round (American Rescue Plan Act funding)
d. Year Round (Reserved for other supplemental funding)
e. Winter
f. Winter (CARES Act funding only)
g. Winter (American Rescue Plan Act funding)
h. Winter (Reserved for other supplemental funding)
i. Summer
j. Summer (CARES Act funding only)
k. Summer (American Rescue Plan Act funding)
l. Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair & Replacement
n. Emergency Furnace Repair and Replacement (CARES Act funding only)
o. Emergency Furnace Repair and Replacement (American Rescue Plan Act funding)
p. Emergency Furnace Repair and Replacement (Reserved for other supplemental funding)
q. Other Crisis Assistance

r. Other Crisis Assistance (CARES Act funding only) s. Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance (Reserved for other supplemental funding)
10. Weatherization
11. Weatherization (CARES Act funding only)
12. Weatherization (American Rescue Plan Act funding)
13. Weatherization (Reserved for other supplemental funding)
III. Number of Assisted Households by Vulnerable Populations
At least one household member who is a member of one the following target groups
Type of LIHEAP assistance		A. 60 years or older (elderly)	B. Disabled	C. Age 5 years or under (young child)	D. Elderly, disabled, or young child
1. Heating
Heating (CARES Act funding only) Heating (American Rescue Plan Act funding) Heating (Reserved for other supplemental funding)
5. Cooling
Cooling (CARES Act funding only) Cooling (American Rescue Plan Act funding) Cooling (Reserved for other supplemental funding)
9.Crisis
a. Year Round
Year Round (CARES Act funding only) Year Round (American Rescue Plan Act funding) Year Round (Reserved for other supplemental funding)
e. Winter
Winter (CARES Act funding) Winter (American Rescue Plan Act funding) Winter (Reserved for other supplemental funding)
i. Summer
Summer (CARES Act funding only) Summer (American Rescue Plan Act funding) Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair and Replacement
Emergency Furnace Repair and Replacement (CARES Act funding only) Emergency Furnace Repair and Replacement (American Rescue Plan Act

funding) p. Emergency Furnace Repair and Replacement (Reserved for other supplemental funding)
q. Other Crisis Assistance
Other Crisis Assistance (CARES Act funding) Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance (Reserved for other supplemental funding)
10. Weatherization
Weatherization (CARES Act funding only) Weatherization (American Rescue Plan Act funding) Weatherization (Reserved for other supplemental funding)
14. Any type of LIHEAP assistance
Any type of LIHEAP assistance (CARES Act funding only) Any type of LIHEAP assistance (American Rescue Plan Act funding)
17. Any type of LIHEAP assistance (Reserved for other supplemental funding)
IV. Number of Assisted Households by Young Child Age Category (Optional)
At least one member who is
Ty pe of LIHEAP assistance			A. Age 2 years or under	B. Age 3 years through 5 years
1. Heating
Heating (CARES Act funding only) Heating (American Rescue Plan Act funding) Heating (Reserved for other supplemental funding)
5. Cooling
Cooling (CARES Act funding only) Cooling (American Rescue Plan Act funding) Cooling (Reserved for other supplemental funding)
9.Crisis
a. Year Round
Year Round (CARES Act funding only) Year Round (American Rescue Plan Act funding) Year Round (Reserved for other supplemental funding)
e. Winter
Winter (CARES Act funding only) Winter (American Rescue Plan Act funding) Winter (Reserved for other supplemental funding)
i. Summer
Summer (CARES Act funding) Summer (American Rescue Plan Act funding) Summer (Reserved for other supplemental funding)
m. Emergency Furnace Repair & Replacement
Emergency Furnace Repair & Replacement (CARES Act funding only) Emergency Furnace Repair & Replacement (American Rescue Plan Act funding) Emergency Furnace Repair & Replacement (Reserved for other supplemental funding)

q. Other Crisis Assistance
Other Crisis Assistance (CARES Act funding only) Other Crisis Assistance (American Rescue Plan Act funding)
t. Other Crisis Assistance (Reserved for other supplemental funding)
10. Weatherization
Weatherization (CARES Act funding only) Weatherization (American Rescue Plan Act funding) Weatherization (Reserved for other supplemental funding)
V. Number of Assisted Households Owner/Renter Status

A. Owner/Renter Status ^{Total Number of}

Households

1. 

   
   

   
   

   
   

   
   

   
   

   0

   
   

   Own

2. Rent with utilities billed separately

3. Rent with utilities in rental fee

4. Other

5. Unknown/not reported

6. TOTAL

VI. Number of Assisted Household Applicants by Race and Ethnicity

1. _Ethnicity Total Number of

Households

1. 

   
   

   
   

   
   

   0

   
   

   Hispanic, Latino, or Spanish Origins

2. Not Hispanic, Latino, or Spanish Origins

3. Unknown/not reported

4. TOTAL

1. _Race Total Number of

Households

1. 

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   0

   
   

   American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Multi-race (two or more of the above)

7. Other

8. Unknown/not reported

9. TOTAL

VII. Number of Assisted Household Applicants by Sex	Total Number of Households
Male Female Unknown/not reported TOTAL
	0

VIII. Number of Assisted Household Members by Race and Ethnicity

1. Ethnicity

1. Hispanic, Latino, or Spanish Origins

2. Not Hispanic, Latino, or Spanish Origins

3. Unknown/not reported

Total Number of Household Members

4. TOTAL

2. Race

Total Number of Household Members

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multi-race (two or more of the above) Other Unknown/not reported TOTAL
	0
IX. Assisted Household Members by Sex	Total Number of Household Members
1. Male
Female Unknown/not reported TOTAL
	0

Remarks

Enter any explanation needed regarding the reliability and/or validity of the above-reported data:

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:	d. Telephone:
b. Title of Authorized Official:	e. Email address:
c. Signature of Authorized Official:	f. Date Submitted:

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