Forms

Note --The forms below are for use by State, Tribal, and Insular Area LIHEAP grantees. Electronic forms are either in a word processing or spreadsheet format.

Grantees may submit completed forms by postal mail, e-mail, or by fax. Forms sent by e-mail can greatly reduce transcription errors and also facilitate our processing of the information. However, a hard copy should be submitted whenever a form requires the signature of the grantee's Chief Executive Officer or his/her designee in certifying to LIHEAP statutory assurances.

Financial Reports

LIHEAP grantees are required to complete and submit annually the following financial forms:

Carryover and Reallotment Report (DOC 28KB) and instructions (DOC 28KB). See related LIHEAP Action Transmittal.

Short Form 269A (PDF 38KB). See related LIHEAP Action Transmittal.

Quarterly Obligation Estimates--Form ACF-535 (XLS 21KB). See related LIHEAP Action Transmittal.

Funding Applications

LIHEAP grantees must apply for LIHEAP funds using the forms and information below. (LIHEAP grantees do not apply for LIHEAP emergency contingency funds.) View an explanation of the types of LIHEAP funding.

1. LIHEAP Block Grant Applications

• Certifications
  
  Debarment, Suspension, and Other Responsibility Matters
  
  Drug Free Work Place
  
  Lobbying
  
  
• Model Plans
  
  Abbreviated Model Plan (DOC 45KB)
  
  Detailed Model Plan (DOC 106KB)
  
  
• Other Information
  
  Application Reminders (DOC 28KB)
  
  Information Memorandum on Model Plan Application for FY 2009 LIHEAP Funding
  
  Schedule for Filing LIHEAP Detailed Applications for FY 2008 - FY 2009 (DOC 38KB)
  
  See also Household Report which is required as part of applying for LIHEAP block grant funds.

2. LIHEAP Leveraging Incentive Funds

Action Transmittal on Submission of Leveraging Reports for FY 2007 Leveraging Incentive Fund Grant Awards

LIHEAP Leveraging Report Form (DOC 67KB)

LIHEAP Leveraging Report Instructions (DOC 63KB)

3. REACH Funds

Action Transmittal on REACH for FY 2007

Grantee Survey

Action Transmittal on LIHEAP Grantee Survey for FY 2007

Instructions for LIHEAP Grantee Survey (DOC 92KB)

Household Report

Action Transmittal on LIHEAP Household Report for FY 2008

FY 2008 LIHEAP Household Report--Long Format (XLS 25KB)

FY 2008 LIHEAP Household Report--Short Format (XLS 20KB)

Instructions for LIHEAP Household Report (DOC 93KB)

Example of Counting Target Group Households (DOC 24KB)