Form 1 LIHEAP Performance Data Form

LIHEAP Performance Data Form

Program Name:	Low Income Home Energy Assistance
Grant Recipient Name:
Report Name:	LIHEAP Performance Data Form
Report Period:
Report Status:

Report Sections

1. MODULE 1 - Grant Recipient Survey

2. Module 2 (Required LIHEAP Performance Measures)

3. Module 2A (Required LIHEAP Performance Measures CARES)

4. Module 2B (Required LIHEAP Performance Measures ARPA)

5. MODULE 3 - OPTIONAL MEASURES

MODULE 1 - Grant Recipient Survey

Section I - Grant Recipient Information

Grant Recipient Name:	Date:	Telephone Number:
Contact Person:	Email Address:

Section II - Reporting Requirements

The 50 States and the District of Columbia are required to complete the LIHEAP Grant Recipient Survey Section of the LIHEAP Performance Data Form in providing estimates of sources and uses of funds, average benefits, and the maximum income cutoff in dollars for a 4-person household for each type of LIHEAP assistance provided in the federal Fiscal Year (FY) for which the report is submitted.

Additionally, the 50 states and the District of Columbia are required to complete Modules 2 and, if open for editing, 2A, and 2B of the LIHEAP Performance Data Form. This federal report provides data on three required LIHEAP Performance Measures for the FY for which the report is submitted. The report consists of the following sections: (1) Energy Burden Targeting, (2) Restoration of Home Energy Service, and (3) Prevention of Loss of Home Energy Service.

Timely response to the required questions on this report is mandatory. The information will be used to respond to Congressional inquiries, to calculate LIHEAP benefit targeting, and to provide FY data for the Department of Health and Human Service’s (HHS's) annual LIHEAP Report to Congress that is required under Section 2610 of the Low-Income Home Energy Act of 1981, as amended [42 U.S.C. § 8621 et seq.]. The data are also used in measuring LIHEAP performance under the Government Performance and Results Act (GPRA) of 1993 [P.L. 103-62], as amended by the GPRA Modernization Act of 2010 [P.L. 111-352]. As the reported data are aggregated, the information in this report is not considered to be confidential.

Click HERE to read the expanded Grant Recipient Survey instructions.

Section III - Estimated Sources of LIHEAP Funds

All possible sources of funds		ALL OF REPORT FY Amount rounded to the nearest dollar
A. All funds except Infrastructure Investment and Jobs Act (IIJA) funds (Items 1-10)
1. FY LIHEAP Block Grant funds (net of Indian tribal set-asides)--regular funds		Pre-populated
2. FY Emergency Contingency funds (net of Indian tribal set-asides)		Pre-populated
3. LIHEAP Block Grant funds from previous FY reallotted to FY		Pre-populated
4. Previous FY unobligated Emergency Contingency funds, not subject to 10% carryover limit		Pre-populated
5. All funds carried over from previous FY (except funds in Items 4, 8, 10, and 12 in this section)		Pre-populated (but can be edited)
6. FY Residential Energy Assistance Challenge (REACH) program funds		Pre-populated
7. Previous FY REACH program funds obligated in FY		Pre-populated
8. FY Leveraging Incentive funds		Pre-populated
9. Previous FY Leveraging Incentive funds obligated in FY		Pre-populated
B. Estimated Subtotal Sources of Funds--Non-Supplemental Funding
10. Sum of Items 1-9. This should equal the amount in Item 15 of Section IV.		Pre-populated
C. All Supplemental Funds (Items 11-12)
11. IIJA funds carried over from previous FY	Pre-populated (but can be edited)
12. IIJA funds (net of Indian tribal set-asides).	Pre-populated
D. Estimated Subtotal Sources of Supplemental Funds
13. Sum of Items 11-12. This should equal the amount in Item 28 of Section IV.	Pre-populated
E. Estimated Total of Sources of All Funds
14. Item 10 plus Item 13. This should equal the amount in Item 31 of Section IV.	Pre-populated

Section IV - Estimated Uses of LIHEAP Funds

ALL OF FY	ALL OF REPORT FY Amount rounded to the nearest dollar
All possible uses of funds	Total funds / awards	Average household benefit (based on expenditures)
A. Type of LIHEAP assistance--non-supplemental funds (Items 1-4)
1. Heating assistance benefits--non-supplemental funds
2. Cooling assistance benefits--non-supplemental funds
3. Crisis assistance benefits by type--non-supplemental funds
a. Winter Crisis benefits--non-supplemental funds
b. Summer Crisis benefits--non-supplemental funds
c. Year-Round Crisis benefits--non-supplemental funds
d. Other Crisis benefits:--non-supplemental funds
(1) Specify--non-supplemental funds
(2) Specify--non-supplemental funds
(3) Specify--non-supplemental funds
4. Weatherization assistance benefits--non-supplemental funds
B. Other Permitted Uses of LIHEAP Funds--non-supplemental funds (Items 5-14)
5. Nominal payments--non-supplemental funds
6. FY unobligated funds (excluding funds in Items 7, 8, 12, and 23) carried over to next FY--non-supplemental funds
7. FY allowable unobligated Emergency Contingency funds, not subject to 10% carryover limit, obligated in next FY--non-supplemental funds	Pre-populated
8. FY Leveraging Incentive funds obligated in next FY--non-supplemental funds	Pre-populated
9. FY LIHEAP funds used to identify, develop & demonstrate Leveraging Incentive activities--non-supplemental funds
10. Assurance 16 activities--non-supplemental funds
11. FY Residential Energy Assistance Challenge (REACH) funds--non-supplemental funds	Pre-populated
12. FY REACH funds obligated in next FY--non-supplemental funds	Pre-populated
13. Administration/planning costs--non-supplemental funds
14. Other non-administrative costs (i.e., non-admin IT system enhancements)--non-supplemental funds
C. Estimated Total Uses of Funds--non-supplemental funds
15. Sum of Items 1-14. This should equal the amount in Item 10 of Section III.	Pre-populated
16. Obligated funding for a given type of assistance in current FY, but will serve households in the subsequent FY--non-supplemental funds	Yes/No
17. Average household benefits are estimated due to unique program operations, rather than directly calculated--non-supplemental funds	Yes/No
D. Type of LIHEAP Assistance--Infrastructure Investment and Jobs Act (IIJA) Funds: (Items 18-21)
18. Heating Assistance benefits--IIJA
19. Cooling Assistance benefits--IIJA
20. Crisis benefits by type--IIJA
a. Winter Crisis benefits--IIJA
b. Summer Crisis benefits--IIJA
c. Year-round Crisis benefits--IIJA
d. Other Crisis benefits--IIJA
(1) Specify--Infrastructure Act Funds
(2) Specify--Infrastructure Act Funds
(3) Specify--Infrastructure Act Funds
21. Weatherization Assistance benefits--IIJA
E. Other Permitted Uses of LIHEAP Funds--IIJA (Items 22-27)
22. Nominal payments—IIJA
23. Unobligated IIJA funds carried over to next FY
24. FY LIHEAP funds used to identify, develop & demonstrate Leveraging Incentive activities—IIJA
25. Assurance 16 activities--IIJA
26. Administration/planning costs--IIJA
27. Other non-administrative costs (i.e., non-admin IT system enhancements)--IIJA
F. Estimated Total Uses of Funds--IIJA
28. Sum of Items 18-27. This should equal the amount in Item 13 in Section III.	Pre-populated
29. Obligated funding for a given type of assistance in current FY, but will serve households in the subsequent FY—IIJA	Yes/No
30. Average household benefits are estimated due to unique program operations, rather than directly calculated--IIJA	Yes/No
G. Estimated Total Uses of All Funds
31. Sum of Items 15 and 28. This should equal the amount in Item 14 of Section III.	Pre-populated
Notes: Include any notes. Please indicate type of LIHEAP assistance and item being referenced.

Module 2 Required LIHEAP Performance Measures--All Households

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB Clearance No.: 0970-0449 ADMINISTRATION FOR CHILDREN AND FAMILIES Expiration Date: 02/28/2025 LIHEAP Performance Data Form for the Current FY Module 2 - Required LIHEAP Performance Measures—All Households
Grant Recipient Name:			Date:			Telephone Number:
Contact Person:			Email Address:
This mandatory LIHEAP Performance Measurement module of the LIHEAP Performance Data Form is for use by the 50 states and the District of Columbia. It provides data on households that received benefits in the report-year’s FY from all funding sources for the three required LIHEAP performance measures: Energy burden targeting, restoration of home energy service, and prevention of loss of home energy service. The data will be included in HHS’s annual LIHEAP Report to Congress. The data are also used in measuring LIHEAP performance under the Government Performance and Results Act of 1993. As the reported data are aggregated, the information in this report is not considered to be confidential.
SECTION V. ENERGY BURDEN TARGETING
		Bill Payment- Assisted Household Main Heating Fuel
	All Households	Electricity		Natural Gas	Fuel Oil		Propane	Other Fuels
A. Unduplicated number of LIHEAP bill payment-assisted households	Auto-calculated
B. All Households with 12 Consecutive Months of Bill Data (Main Heating Fuel and Electricity)
1. Unduplicated number of households with 12 consecutive months of bill data (main heating fuel and electricity)	Auto-calculated
2. Average annual household income	Auto-calculated
3. Average annual total LIHEAP benefit per household (including Heating, Cooling, Crisis, and Supplemental benefits)	Auto-calculated
4. Average annual main heating fuel bill	Auto-calculated
5. Average annual electricity bill	Auto-calculated	$0
6. Average annual total residential energy bill	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
7. Average annual burden before receiving LIHEAP	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
8. Average annual burden after receiving LIHEAP	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
9. Average percentage point change in energy burden	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
10. Average percentage reduction in energy burden	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
C. High-Burden Households with 12 Consecutive Months of Bill Data (Main Heating Fuel and Electricity)
1. Unduplicated number of high-burden households (top 25%) with 12 consecutive months of bill data (main heating fuel and electricity)	Auto-calculated
2. Average annual household income for high-burden households	Auto-calculated
3. Average annual total LIHEAP benefit per high-burden household (including Heating, Cooling, Crisis, Supplemental benefits)	Auto-calculated
4. Average annual main heating fuel bill for high-burden households	Auto-calculated
5. Average annual electricity bill for high-burden households	Auto-calculated	$0
6. Average annual total residential energy bill for high-burden households	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
7. Average annual burden before receiving LIHEAP for high-burden households	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
8. Average annual burden after receiving LIHEAP for high-burden households	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated

9. Average percentage point change in energy burden for high-burden households	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
10. Average percentage reduction in energy burden for high-burden households	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
D. Benefit Targeting Index for high-burden households	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
E. Burden Reduction Targeting Index for high-burden households	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
SECTION VI. RESTORATION OF HOME ENERGY SERVICE
		Energy Source (where LIHEAP benefit was applied)
A. All occurrences of LIHEAP households that had:	All Occurrences	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
1. Energy service restored after disconnection	Auto-calculated
2. Fuel delivered to home that ran out of fuel	Auto-calculated
3. Repair/replacement of inoperable home energy equipment	Auto-calculated
SECTION VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE
		Energy Source (where LIHEAP benefit was applied)
A. All occurrences of LIHEAP households that had:	All Occurrences	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
1. Past due notice or utility disconnect notice for which LIHEAP assistance prevented disconnection	Auto-calculated
2. Imminent risk of running out of fuel for which LIHEAP assistance prevented depletion	Auto-calculated
3. Repair/replacement of faulty but operable equipment by LIHEAP assistance to prevent imminent home energy loss	Auto-calculated
NOTES: Include any notes below. Please indicate type of LIHEAP assistance and item being referenced.

Module 2A. Required LIHEAP Performance Measures--CARES Act

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB Clearance No.: 0970-0449 ADMINISTRATION FOR CHILDREN AND FAMILIES Expiration Date: 02/28/2025 LIHEAP Performance Data Form for the Current FY Module 2A – Required LIHEAP Performance Measures--CARES Act Subset
Grant Recipient Name:			Date:			Telephone Number:
Contact Person:			Email Address:
This mandatory LIHEAP Performance Measurement module of the LIHEAP Performance Data Form is for use by the 50 states and the District of Columbia. It provides data on households that received benefits in the report-year’s FY from the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) [P.L. 116-136] for the three required LIHEAP performance measures: Energy burden, restoration of home energy service, and prevention of loss of home energy service. The data will be included in HHS's annual LIHEAP Report to Congress. The data are also used in measuring LIHEAP performance under the Government Performance and Results Act of 1993. As the reported data are aggregated, the information in this report is not considered to be confidential.
SECTION V. ENERGY BURDEN TARGETING
		Bill Payment- Assisted Household Main Heating Fuel
	All Households	Electricity		Natural Gas	Fuel Oil		Propane	Other Fuels
A. Unduplicated number of LIHEAP bill payment-assisted households--CARES Act	Auto-calculated
B. All Households with 12 Consecutive Months of Bill Data (Main Heating Fuel and Electricity)
1. Unduplicated number of households with 12 consecutive months of bill data (main heating fuel and electricity)--CARES Act	Auto-calculated
2. Average annual household income--CARES Act	Auto-calculated
3. Average annual total LIHEAP benefit per household (including Heating, Cooling, Crisis, and Supplemental Benefits)--CARES Act	Auto-calculated
4. Average annual main heating fuel bill--CARES Act	Auto-calculated
5. Average annual electricity bill--CARES Act	Auto-calculated	$0
6. Average annual total residential energy bill--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
7. Average annual burden before receiving LIHEAP--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
8. Average annual burden after receiving LIHEAP--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
9. Average percentage point change in energy burden--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
10. Average percentage reduction in energy burden--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
C. High-Burden Households with 12 Consecutive Months of Bill Data (Main Heating Fuel and Electricity)
1. Unduplicated number of high-burden households (top 25%) with 12 consecutive months of bill data (main heating fuel and electricity)--CARES Act	Auto-calculated
2. Average annual household income for high-burden households--CARES Act	Auto-calculated
3. Average annual total LIHEAP benefit per high-burden household (including Heating, Cooling, Crisis, Supplemental Benefits)--CARES Act	Auto-calculated
4. Average annual main heating fuel bill for high-burden households--CARES Act	Auto-calculated
5. Average annual electricity bill for high-burden households--CARES Act	Auto-calculated	$0
6. Average annual total residential energy bill for high-burden households--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
7. Average annual burden before receiving LIHEAP for high-burden households--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
8. Average annual burden after receiving LIHEAP for high-burden households--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
9. Average percentage point change in energy burden for high-burden households--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
10. Average percentage reduction in energy burden for high-burden households--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
D. Benefit targeting index for high-burden households--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
E. Burden reduction targeting index for high-burden households--CARES Act	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
SECTION VI. RESTORATION OF HOME ENERGY SERVICE
		Energy Source (where LIHEAP benefit was applied)
A. All occurrences of LIHEAP households that had:	All Occurrences	Electricity		Natural Gas	Fuel Oil		Propane	Other Fuels
1. Energy service restored after disconnection with CARES Act assistance, alone or in combination with other sources	Auto-calculated
2. Fuel delivered to home that ran out of fuel with CARES Act assistance, alone or in combination with other sources	Auto-calculated
3. Repair/replacement of inoperable home energy equipment with CARES Act assistance, alone or in combination with other sources	Auto-calculated
SECTION VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE
		Energy Source (where LIHEAP benefit was applied)
A. All occurrences of LIHEAP households that had:	All Occurrences	Electricity		Natural Gas	Fuel Oil		Propane	Other Fuels
1. Past due notice or utility disconnect notice for which LIHEAP CARES Act assistance, alone or in combination with other sources, prevented disconnection	Auto-calculated
2. Imminent risk of running out of fuel for which LIHEAP CARES Act assistance, alone or in combination with other sources, prevented depletion	Auto-calculated
3. Repair/replacement of faulty but operable equipment by LIHEAP CARES Act, alone or in combination with other sources, to prevent imminent home energy loss	Auto-calculated
NOTES: Include any notes below about CARES Act-assisted households. Please indicate type of LIHEAP assistance and item being referenced.

Module 2B. Required LIHEAP Performance Measures--ARPA

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB Clearance No.: 0970-0449 ADMINISTRATION FOR CHILDREN AND FAMILIES Expiration Date: 02/28/2025 LIHEAP Performance Data Form for the Current FY Module 2B - Required LIHEAP Performance Measures--ARPA Subset
Grant Recipient Name:			Date:			Telephone Number:
Contact Person:			Email Address:
This mandatory LIHEAP Performance Measurement module of the LIHEAP Performance Data Form is for use by the 50 states and the District of Columbia. It provides data on households that received benefits in the report-year’s FY from the American Rescue Plan Act of 2021 (ARPA) [P.L. 117-2] for the three required LIHEAP Performance Measures: Energy burden, restoration of home energy service, and prevention of loss of home energy service. The data will be included in HHS's annual LIHEAP Report to Congress. The data are also used in measuring LIHEAP performance under the Government Performance and Results Act of 1993. As the reported data are aggregated, the information in this report is not considered to be confidential.
SECTION V. ENERGY BURDEN TARGETING
		Bill Payment- Assisted Household Main Heating Fuel
	All Households	Electricity		Natural Gas	Fuel Oil		Propane	Other Fuels
A. Unduplicated number of LIHEAP bill payment-assisted households--ARPA	Auto-calculated
B. All Households with 12 Consecutive Months of Bill Data (Main Heating Fuel and Electricity)
1. Unduplicated number of households with 12 consecutive months of bill data (main heating fuel and electricity)—ARPA	Auto-calculated
2. Average annual household income--	Auto-calculated
3. Average annual total LIHEAP benefit per household (including Heating, Cooling, Crisis, and Supplemental Benefits)--ARPA	Auto-calculated
4. Average annual main heating fuel bill--ARPA	Auto-calculated
5. Average annual electricity bill--ARPA	Auto-calculated	$0
6. Average annual total residential energy bill--ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
7. Average annual burden before receiving LIHEAP--ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
8. Average annual burden after receiving LIHEAP--ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
9. Average percentage point change in energy burden--ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
10. Average percentage reduction in energy burden--ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
C. High-Burden Households with 12 Consecutive Months of Bill Data (Main Heating Fuel and Electricity)
1. Unduplicated number of high-burden households (top 25%) with 12 consecutive months of bill data (main heating fuel and electricity)--ARPA	Auto-calculated
2. Average annual household income for high-burden households--ARPA	Auto-calculated
3. Average annual total LIHEAP benefit per high-burden household (including Heating, Cooling, Crisis, Supplemental Benefits)--ARPA	Auto-calculated
4. Average annual main heating fuel bill for high-burden households--ARPA	Auto-calculated
5. Average annual electricity bill for high-burden households--ARPA	Auto-calculated	$0
6. Average annual total residential energy bill for high-burden households—ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
7. Average annual burden before receiving LIHEAP for high-burden households--ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated
8. Average annual burden after receiving LIHEAP for high-burden households--ARPA	Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated		Auto-calculated	Auto-calculated

9. Average percentage point change in energy burden for high-burden households--ARPA	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
10. Average percentage reduction in energy burden for high-burden households--ARPA	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
D. Benefit targeting index for high-burden households--ARPA	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
E. Burden reduction targeting index for high-burden households--ARPA	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated
SECTION VI. RESTORATION OF HOME ENERGY SERVICE
		Energy Source (where LIHEAP benefit was applied)
A. All occurrences of LIHEAP households that had:	All Occurrences	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
1. Energy service restored after disconnection with ARPA assistance, alone or in combination with other sources	Auto-calculated
2. Fuel delivered to home that ran out of fuel with ARPA assistance, alone or in combination with other sources	Auto-calculated
3. Repair/replacement of inoperable home energy equipment with ARPA assistance, alone or in combination with other sources	Auto-calculated
SECTION VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE
		Energy Source (where LIHEAP benefit was applied)
A. All occurrences of LIHEAP households that had:	All Occurrences	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
1. Past due notice or utility disconnect notice for which LIHEAP ARPA assistance, alone or in combination with other sources, prevented disconnection	Auto-calculated
2. Imminent risk of running out of fuel for which LIHEAP ARPA assistance, alone or in combination with other sources, prevented depletion	Auto-calculated
3. Repair/replacement of faulty but operable equipment by LIHEAP ARPA, alone or in combination with other sources, to prevent imminent home energy loss	Auto-calculated
NOTES: Include any notes below about ARPA-assisted households. Please indicate type of LIHEAP assistance and item being referenced.

MODULE 3 - OPTIONAL MEASURES

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB Clearance No.: 0970-0449 ADMINISTRATION FOR CHILDREN AND FAMILIES Expiration Date: 02/28/2025 LIHEAP Performance Data Form for the Current FY Module 3 – Optional LIHEAP Performance Measures
Grant Recipient Name:		Date:			Telephone Number:
Contact Person:		Email Address:
This optional LIHEAP Performance Measurement module of the LIHEAP Performance Data Form is for use by the 50 states and the District of Columbia. It provides additional data on households that received benefits in the report-year’s FY from all funding sources. It contains more advanced questions that supplement the data that enter into the three required LIHEAP performance measures: Energy burden targeting, restoration of home energy service, and prevention of loss of home energy service. The data are also used in measuring LIHEAP performance under the Government Performance and Results Act of 1993. As the reported data are aggregated, the information in this report is not considered to be confidential.
SECTION V. ENERGY BURDEN TARGETING (OPTIONAL MEASURES)
		Bill Payment- Assisted Household Main Heating Fuel
A. All households with 12 consecutive months of bill data (main heating fuel and electricity)	All Households	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
1. Average annual electricity usage	Auto-calculated
2. Average annual main heating usage	Auto-calculated
B. High-Burden Households with 12 Consecutive Months of Bill Data (Main Heating Fuel and Electric)
1. Average annual electricity usage by high-burden households	Auto-calculated
2. Main heating fuel usage by high-burden households	Auto-calculated
C. Unduplicated Number of LIHEAP Bill Payment-Assisted Households That Use:
1. Electricity as supplemental heating fuel	Auto-calculated
2. Wood as supplemental heating fuel	Auto-calculated
3. Other supplemental heating fuel	Auto-calculated
4. Central air conditioning (A/C)	Auto-calculated
5. Window/wall A/C (including evaporative cooler)	Auto-calculated
SECTION VI. RESTORATION OF HOME ENERGY SERVICE (OPTIONAL MEASURES)
		Energy Source
A. Unduplicated count of all LIHEAP-assisted households that had:	All Households	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
1. Restorations of home energy service	Auto-calculated
SECTION VII. PREVENTION OF LOSS OF HOME ENERGY SERVICE (OPTIONAL MEASURES)
		Energy Source
A. Unduplicated count of all LIHEAP-assisted households that had:	All Households	Electricity	Natural Gas	Fuel Oil	Propane	Other Fuels
1. Preventions of loss of home energy service	Auto-calculated
NOTES: Include any notes below about optional performance measures. Please indicate type of LIHEAP assistance and item being referenced

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:

Page 1 of 23