Mandatory Grant Application SF-424
Tribal code
Ask Donna
What actually matters in this document.
Text
Mandatory Grant Application SF-424
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
* 1.a. Type of Submission:
Plan
* 1.b. Frequency:
Annual
* 1.c. Consolidated Application/
Plan/Funding Request?
Explanation:
* 1.d. Version:
Initial
Resubmission
Revision
Update
State Use Only:
2. Date Received:
3. Applicant Identifier:
4a. Unique Entity Identifier (UEI)
KRYSABHAADZ9
5. Date Received By State:
4b. Federal Award Identifier:
6. State Application Identifier:
7. APPLICANT INFORMATION
* a. Legal Name: Otoe-Missouria Tribe
* b. Address:
* Street 1:
8151 N. HIGHWAY 177
Street 2:
* City:
RED ROCK
County:
* State:
OK
Province:
* Country:
United States
* Zip / Postal
Code:
Oklahoma
74651 -
c. Organizational Unit:
Department Name:
Division Name:
d. Name and contact information of person to be contacted on matters involving this application: (person will be listed on Notice of Funding
Awards and on the U.S. Department of Health and Human Services' LIHEAP contact list webpage)
* First Name:
Samantha
* Last Name:
Moran
Title:
Acting ICW Program Director
Organizational Affiliation:
Otoe-Missouria Tribe of Indian
* Telephone Number:
5803075041
Fax Number
* Email:
smoran@omtribe.org
* 8. TYPE OF APPLICANT:
I: Indian/Native American Tribal Government (Federally Recognized)
* a. Is the applicant a Tribal Consortium:
Yes
No
* b. If yes please attach at least one the following documentation:
Catalog of Federal Domestic
Assistance Number:
9. CFDA Numbers and Titles
93.568
CFDA Title:
Low-Income Home Energy Assistance Program
10. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
3LIHEAP
11. AREAS AFFECTED BY FUNDING:
Garfield and Noble Counties
12. CONGRESSIONAL DISTRICTS OF APPLICANT:
3
13. FUNDING PERIOD:
a. Start Date:
10/01/2025
b. End Date:
09/30/2026
* 14. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?
a. This submission was made available to the State under Executive Order 12372
Page 2 of 47
Process for review on:
b. Program is subject to E.O. 12372 but has not been selected by State for review.
c. Program is not covered by E.O. 12372.
*15. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
YES
NO
If Yes, explain:
16. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true,
complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I
accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative
penalties. (U.S. Code, Title 218, Section 1001)
**I Agree
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency
specific instructions.
17a. Typed or Printed Name and Title of Authorized Certifying Official
17c. Telephone (area code, number and extension)
17d. Email Address
17b. Signature of Authorized Certifying Official
17e. Date Report Submitted (Month, Day, Year)
Page 3 of 47
Section 1 - Program Components
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)Use of this model plan is optional. However, the information requested is
required in order to receive a Low Income Home Energy Assistance Program (LIHEAP) grant.Public reporting burden for this collection of
information is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining the data
needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number.
Section 1 Program Components
Program Components, 2605(a), 2605(b)(1) - Assurance 1, 2605(c)(1)(C)
1.1 Check which components you will operate under the LIHEAP program.
(Note: You must provide information for each component designated here as requested elsewhere in
this plan.)
Dates of Operation
Start Date
End Date
Heating assistance
10/01/2024
09/30/2025
Cooling assistance
10/01/2024
09/30/2025
Summer crisis assistance
10/01/2024
09/30/2025
Winter crisis assistance
10/01/2024
09/30/2025
Year-round crisis assistance
Weatherization assistance
Provide further explanation for the dates of operation, if necessary
Estimated Funding Allocation, 2604(C), 2605(k)(1), 2605(b)(9), 2605(b)(16) - Assurances 9 and 16
1.2 Estimate what amount of available LIHEAP funds will be used for each component that you will operate:
The total of all percentages must add up to 100%.
Percentage ( % )
Prior year totals
Heating assistance
35.00%
35.00%
Cooling assistance
35.00%
35.00%
Summer crisis assistance
15.00%
30.00%
Winter crisis assistance
15.00%
0.00%
Year-round crisis assistance
0.00%
0.00%
Weatherization assistance
0.00%
0.00%
Carryover to the following federal fiscal year
0.00%
0.00%
Administrative and planning costs
0.00%
0.00%
Services to reduce home energy needs including needs assessment (Assurance 16)
0.00%
0.00%
Used to develop and implement leveraging activities
TOTAL
0.00%
0.00%
100.00%
100.00%
Tribal grant recipients: direct-grant tribes, tribal organizations, or territories with allotments of $20,000 or less may use for planning and administration
up to 20% of the funds payable. Grant recipients that are direct grant tribes, tribal organizations, or territories with allotments over $20,000 may use for
planning and administration purposes up to 20% of the first $20,000 (or $4,000) plus 10% of the funds payable that exceeds $20,000. Any administrative
costs in excess of these limits must be paid from non-federal sources.
Page 4 of 47
Alternate Use of Crisis Assistance Funds, 2605(c)(1)(C)
1.3 The funds reserved for winter crisis assistance that have not been expended by March 15 will be reprogrammed to:
Heating assistance
Cooling assistance
Weatherization assistance
Other (specify:)
Categorical Eligibility, 2605(b)(2)(A) - Assurance 2, 2605(c)(1)(A), 2605(b)(8A) - Assurance 8
1.4 Do you consider households categorically eligible if at least one household member receives at least one of the following categories of benefits
in the left column below?
Yes
No
If you answered "Yes" to question 1.4, you must complete the table below and answer questions 1.5 and 1.6.
Heating
Cooling
Crisis
Weatherization
TANF
Yes
No
Yes
No
Yes
No
Yes
No
SSI
Yes
No
Yes
No
Yes
No
Yes
No
SNAP
Yes
No
Yes
No
Yes
No
Yes
No
Means-tested Veterans Programs
Yes
No
Yes
No
Yes
No
Yes
No
1.4a. Provide your definition of categorical eligibility. Please explain how households are categorically eligible (i.e, do all household members
need to receive the benefits or just one member, is there a data exchange in place?) and how categorical eligibility streamlines the LIHEAP
application process.
1.5 Do you automatically enroll households without a direct annual application?
Yes
No
If Yes, explain:
1.6 How do you ensure there is no difference in the treatment of categorically eligible households from those not receiving other public assistance
when determining eligibility and benefit amounts?
Verification of all income.
SNAP Nominal Payments
1.7a Do you allocate LIHEAP funds toward a nominal payment for SNAP households?
Yes
No
If you answered "Yes" to question 1.7a, you must provide a response to questions 1.7b, 1.7c, and 1.7d.
1.7b Amount of Nominal Assistance: $0.00
1.7c Frequency of Assistance
Once Per Year
Once every five years
Other - Describe:
1.7d How do you confirm that the household receiving a nominal payment has an energy cost or need?
Determination of Eligibility - Countable Income
1.8. In determining a household's income eligibility for LIHEAP, do you use gross income or net income?
Gross Income
Net Income
Other - Describe
1.9. Select all the applicable forms of countable income used to determine a household's income eligibility for LIHEAP
Wages
Self - Employment Income
Contract Income
Payments from mortgage or Sales Contracts
Page 5 of 47
Unemployment insurance
Strike Pay
Social Security Administration (SSA ) benefits
Including MediCare
deduction
Excluding MediCare deduction
Supplemental Security Income (SSI )
Retirement / pension benefits
General Assistance benefits
Temporary Assistance for Needy Families (TANF) benefits
Loans that need to be repaid
Cash gifts
Savings account balance
One-time lump-sum payments, such as rebates/credits, winnings from lotteries, refund deposits, etc.
Jury duty compensation
Rental income
Income from employment through Workforce Investment Act (WIA)
Income from work study programs
Alimony
Child support
Interest, dividends, or royalties
Commissions
Legal settlements
Insurance payments made directly to the insured
Insurance payments made specifically for the repayment of a bill, debt, or estimate
Veterans Administration (VA) benefits
Earned income of a child under the age of 18
Balance of retirement, pension, or annuity accounts where funds cannot be withdrawn without a penalty.
Income tax refunds
Stipends from senior companion programs, such as VISTA
Funds received by household for the care of a foster child
Ameri-Corp Program payments for living allowances, earnings, and in-kind aid
Page 6 of 47
Reimbursements (for mileage, gas, lodging, meals, etc.)
Other
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
1.10 Do you have an online application process
Yes
No
1.10a If yes, describe the type of online application (Select all boxes that apply)
A PDF version of the application is available online and can be downloaded, filled out and mailed in for processing.
A state-wide online application that allows a customer to complete data entry and submit an application electronically for processing.
One or more locally available online applications that allows a customer to complete data entry and submit an application electronically
for processing.
Online application that is also mobile friendly
Other, please describe
Please include a link(s) to a statewide application, if available:
1.10b Can all program components be applied for online?
Yes
No
If no, explain which components can and cannot be applied for online.
none
1.11 Do you have a process for conducting and completing applications by phone
Yes
1.12 Do you or any of your subrecipients require in person appointments in order to apply
No
Yes
No
If yes, please provide more information regarding why in-person appointments are required and in what circumstances they are required.
1.13 How can applicants submit documentation for verification? Select all that apply:
In-person
Portal application
Other, please describe
Hidden for Section 1
Page 7 of 47
Section 2 - HEATING ASSISTANCE
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 2 - Heating Assistance
Eligibility, 2605(b)(2) - Assurance 2
2.1 Designate the income eligibility threshold used for the heating component:
Add
Household size
Eligibility Guideline
All Household Sizes
1
2.2 Do you have additional eligibility requirements for
Heating Assistance?
Eligibility Threshold
State Median Income
Yes
60.00%
No
2.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test?
Yes
No
If yes, describe: Do you have additional/differing eligibility policies for:
Renters?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, describe:
Renters Living in subsidized housing?
If yes, describe:
Renters with utilities included in the rent?
If yes, describe:
Do you give priority in eligibility to:
Older Adults (60 years or older)?
If yes, describe:
Individuals with a disability?
If yes, describe:
Young children?
If yes, describe:
Households with high energy burdens?
If yes, describe:
Other?
If yes, describe:
Explanations of policies for each "yes" checked above:
Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
2.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods,
etc.
Eligibility determination sheets are attached to each returned application. This form is used as a compliance form to ensure all
components of the application are complete and allows staff to calculate priority categories (vulnerable populations).
2.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Individual bill
Page 8 of 47
Dwelling type
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:
Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
2.6 Describe estimated benefit levels for the fiscal year for which this plan applies. Please note: the maximum and minimum benefits must be
shown in the payment matrix.
Minimum Benefit
$50
Maximum Benefit
2.7 Do you provide in-kind (e.g., blankets, space heaters) and/or other forms of benefits?2
Yes
$500
No
If yes, describe.
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 9 of 47
Section 3 - COOLING ASSISTANCE
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 3 - Cooling Assistance
Eligibility, 2605(c)(1)(A), 2605 (b)(2) - Assurance 2
3.1 Designate The income eligibility threshold used for the Cooling component:
Add
Household size
Eligibility Guideline
All Household Sizes
1
3.2 Do you have additional eligibility requirements for
Cooling assistance?
State Median Income
Yes
Eligibility Threshold
60.00%
No
3.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, describe:
Do you have additional/differing eligibility policies for:
Renters?
If yes, describe:
Renters Living in subsidized housing?
If yes, describe:
Renters with utilities included in the rent?
If yes, describe:
Do you give priority in eligibility to:
Older Adults (60 years or older)?
If yes, describe:
Individuals with a disability?
If yes, describe:
Young children?
If yes, describe:
Households with high energy burdens?
If yes, describe:
Other?
If yes, describe:
Explanations of policies for each "yes" checked above:
3.4 Describe how you prioritize the provision of cooling assistance to vulnerable populations, e.g., benefit amounts, early application periods,
etc.
They gain more points.
Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
3.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Page 10 of 47
Individual bill
Dwelling type
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:
Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
3.6 Describe estimated benefit levels for the fiscal year for which this plan applies. Please note: the maximum and minimum benefits must be
shown in the payment matrix.
Minimum Benefit
$50
Maximum Benefit
3.7 Do you provide in-kind (e.g., fans, air conditioners) and/or other forms of benefits?
Yes
$500
No
If yes, describe.
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 11 of 47
Section 4 - CRISIS ASSISTANCE
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 4: CRISIS ASSISTANCE
Eligibility - 2604(c), 2605(c)(1)(A)
4.1 Designate the income eligibility threshold used for the crisis component
Add
1
Household size
Eligibility Guideline
All Household Sizes
Eligibility Threshold
State Median Income
60.00%
4.2 Provide your LIHEAP program's definition for determining a crisis. If you administer multiple crisis assistance programs (winter, summer,
and/or year-round), Include all program definitions.
Crisis is a non life threatening home energy situation due to heating/cooling source. Income eligible households must have a cut-off/
disconnect notice or household must have less than 25% propane for heating or households with utilities inclusive with rent costs must have a
written statement of threat of eviction due to unpaid of rent that includes utilities for heating/cooling source. Staff will resolve energy crisis within
48 hours after eligible household applies with completed application.
4.3 What constitutes a life-threatening crisis?
Life-threatening crisis is defined as any home energy situation that causes imminent threat to the health and safety of household members.
Income eligible household must have a 42 hour or less cut-off/disconnect notice, or household must have less than 10% propane for heating, or
household with utilities inclusive with rent costs must have eviction notice citing unpaid rent. Staff will resolve energy crisis within 18 hours after
eligible household applies with completed application.
Crisis Requirement, 2604(c)
4.4 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? 48Hours
4.5 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening
situations? 18Hours
Crisis Eligibility, 2605(c)(1)(A)
Winter
Crisis
4.6 Do you have additional eligibility requirements for Crisis Assistance?
4.7 Check the appropriate boxes below to indicate type(s) of assistance provided
0
Do you require an Assets test?
Do you give priority in eligibility to:
Older Adults (60 years or older)?
Individuals with a disability?
Young Children?
Households with high energy burdens?
Other (Specify):
In Order to receive crisis assistance:
Must the household have received a shut-off notice or have a near empty tank?
Must the household have been shut off or have an empty tank?
Must the household have exhausted their regular heating benefit?
Must renters with heating costs included in their rent have received an eviction notice?
Must heating/cooling be medically necessary?
Page 12 of 47
Summer
Crisis
Year-Round
Crisis
Must the household have non-working heating or cooling equipment?
Other (Specify):
Do you have additional/differing eligibility policies for:
Renters?
Renters living in subsidized housing?
Renters with utilities included in the rent?
Explanations of policies for each "yes" checked above:
Due to limited or no income the tribe will give priority to its elders, disabled and children. And to be considered crisis client must have a
shut off notice otherwise if they don't preference will be given elsewhere first.
Determination of Benefits
4.8 How do you handle crisis situations?
Separate component
Benefit Fast Track, no separate amount of crisis funds is issued. Rather benefits are issued to crisis customers within crisis
response time frames.
Other - Describe:
4.9 If you have a separate component, how do you determine crisis assistance benefits?
Amount to resolve the crisis. $0
Other - Describe:
Eligible maximum benefit amount according to current benefit matrix.
Crisis Requirements, 2604(c)
4.10 Do you accept applications for energy crisis assistance at sites that are geographically accessible to all households in the area to be served?
Yes
No
Explain.
4.11 Do you provide individuals who are individuals with a disability the means to:
Submit applications for crisis benefits without leaving their homes?
Yes
No
If No, explain.
Travel to the sites at which applications for crisis assistance are accepted?
Yes
No
If No, explain.
If you answered "No" to both options in question 4.11, please explain alternative means of intake to those who are homebound or physically
disabled?
Benefit Levels, 2605(c)(1)(B)
4.12 Indicate the maximum benefit for each type of crisis assistance offered.
Winter Crisis
$500.00 maximum benefit
Summer Crisis
$500.00 maximum benefit
Year-round Crisis
$500.00 maximum benefit
4.13 Do you provide in-kind (e.g. blankets, space heaters, fans) and/or other forms of benefits?
Yes
No If yes, Describe
4.14 Do you provide for equipment repair or replacement using crisis funds?
Yes
No
If you answered "Yes" to question 4.14, you must complete question 4.15.
4.15 Check appropriate boxes below to indicate type(s) of assistance provided.
Winter
Crisis
Summer
Crisis
Year-round Crisis
Heating system repair
Page 13 of 47
Heating system replacement
Cooling system repair
Cooling system replacement
Wood stove purchase
Pellet stove purchase
Solar panel(s)
Utility poles / gas line hook-ups
Other (Specify):
4.16 Do any of the utility vendors you work with enforce a moratorium on shut offs?
Yes
No
If you responded "Yes" to question 4.16, you must respond to question 4.17.
4.17 Describe the terms of the moratorium and any special dispensation received by LIHEAP clients during or after the moratorium period.
4.18 If you experience a natural disaster, do you intend to utilize LIHEAP crisis funds to address disaster related crisis situations?
No
Yes
If yes, describe
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 14 of 47
Section 5 - WEATHERIZATION ASSISTANCE
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 5: WEATHERIZATION ASSISTANCE
Eligibility, 2605(c)(1)(A), 2605(b)(2) - Assurance 2
5.1 Designate the income eligibility threshold used for the Weatherization component
Add
Household Size
Eligibility Guideline
Eligibility Threshold
0.00%
1
5.2 Do you enter into an interagency agreement to have another government agency administer a WEATHERIZATION component?
No
Yes
5.3 If yes, name the agency and attach a copy of the Internal Agreement or Contract.
5.4 Is there a separate monitoring protocol for weatherization?
Yes
No
WEATHERIZATION - Types of Rules
5.5 Under what rules do you administer LIHEAP weatherization? (Check only one.)
Entirely under LIHEAP (not DOE) rules
Entirely under DOE WAP (not LIHEAP) rules
Mostly under LIHEAP rules with the following DOE WAP rule(s) where LIHEAP and WAP rules differ (Check all that apply):
Income Threshold
Weatherization of entire multi-family housing structure is permitted if at least 66% of units (50% in 2- & 4-unit buildings) are
eligible units or will become eligible within 180 days
Weatherize shelters temporarily housing primarily low income persons (excluding nursing homes, prisons, and similar institutional
care facilities).
Other - Describe:
Mostly under DOE WAP rules, with the following LIHEAP rule(s) where LIHEAP and WAP rules differ (Check all that apply.)
Income Threshold
Weatherization not subject to DOE WAP maximum statewide average cost per dwelling unit.
Weatherization measures are not subject to DOE Savings to Investment Ration (SIR ) standards.
Other - Describe:
Eligibility, 2605(b)(5) - Assurance 5
5.6 Do you require an assets test?
Yes
No
5.7 Do you have additional/differing eligibility policies for :
Renters
Yes
No
Yes
No
Yes
No
Older Adults?
Yes
No
Individuals with a disability?
Yes
No
Young Children?
Yes
No
Yes
No
Renters living in subsidized
housing?
Renters with utilities included in the
rent?
5.8 Do you give priority in eligibility to:
House holds with high energy
burdens?
Page 15 of 47
Other?
Yes
No
If you selected "Yes" for any of the options in questions 5.6, 5.7, or 5.8, you must provide further explanation of these policies in the text field
below.
Benefit Levels
5.9 Do you have a maximum LIHEAP weatherization benefit/expenditure per household?
Yes
No
5.9a If yes, what is the maximum? $0
5.10 Do you use an Average Cost per Unit (ACPU).
Yes
No
5.10a If so, what is the ACPU amount? $0
Types of Assistance, 2605(c)(1), (B) & (D)
5.11 What LIHEAP weatherization measures do you provide ? (Check all categories that apply.)
Weatherization needs assessments/audits
Energy related roof repair
Caulking and insulation
Major appliance repairs
Storm windows
Major appliance replacement
Furnace/heating system modifications/repairs
Windows/sliding glass doors
Furnace replacement
Doors
Cooling system modifications/repairs
Water Heater
Water conservation measures
Cooling system replacement
Roof top solar
Community solar projects
Compact florescent light bulbs
Other - Describe:
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 16 of 47
Section 6 - Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 6: Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A)
6.1 Select all outreach activities that you conduct that are designed to assure that eligible households are made aware of all LIHEAP assistance
available:
Place posters/flyers in local and county social service offices, offices of aging, Social Security offices, VA, etc.
Publish articles in local newspapers or broadcast media announcements.
Include inserts in energy vendor billings to inform individuals of the availability of all types of LIHEAP assistance.
Mass mailing(s) to prior-year LIHEAP recipients.
Inform low income applicants of the availability of all types of LIHEAP assistance at application intake for other lowincome programs.
Execute interagency agreements with other low-income program offices to perform outreach to target groups.
Web Posting
Texting
Events
Social Media
Other (specify):
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 17 of 47
Section 7 - Coordination, 2605(b)(4) - Assurance 4
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 7: Coordination, 2605(b)(4) - Assurance 4
7.1 Describe how you will ensure that the LIHEAP program is coordinated with other programs available to low-income households (TANF,
SSI, WAP, etc.).
Joint application for multiple programs (indicate programs included)
Intake referrals to/from other programs (indicate programs included) We network with other tribal programs.
One - stop intake centers
Other - Describe:
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 18 of 47
Section 8 - Agency Designation,, 2605(b)(6) - Assurance 6
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 8: Agency Designation, 2605(b)(6) - Assurance 6 (Required for state Grant
recipients and the Commonwealth of Puerto Rico)
8.1 How would you categorize the primary responsibility of your State agency?
Administration Agency
Commerce Agency
Community Services Agency
Energy/Environment Agency
Housing Agency
State Department of Welfare (administers TANF, SNAP, and/or Medicaid)
Economic Development Agency
Other - Describe:
Include current list of subrecipient name, main office address (do not list P.O. Box), phone number, county(s) served, Congressional District, and
UEI number. Used for Near hotline and OCS Service Provider Tool and clearinghouse.
Alternate Outreach and Intake, 2605(b)(15) - Assurance 15
If you selected "State Department of Welfare (administers TANF, SNAP, and/or Medicaid)" in question 8.1, you must complete questions 8.2, 8.
3, and 8.4, as applicable.
8.2 How do you provide alternate outreach and intake for heating assistance?
8.3 How do you provide alternate outreach and intake for cooling assistance?>
8.4 How do you provide alternate outreach and intake for crisis assistance?
8.5 LIHEAP Component Administration.
Heating
Cooling
Crisis
Weatherization
8.5a Who determines client eligibility?
8.5b Who processes benefit payments to gas and
electric vendors?
8.5c who processes benefit payments to bulk fuel
vendors?
8.5d Who performs installation of weatherization
measures?
Include a current list of subrecipient(s) name, main office address (do not list P.O. Box), phone
Page 19 of 47
number, county(s) served, Congressional District, and UEI number.
If any of your LIHEAP components are not centrally-administered by a state agency, you must complete questions 8.6, 8.7, 8.8, and, if
applicable, 8.9.
8.6 What is your process for selecting local administering agencies?
8.7 How many local administering agencies do you use?
8.8 Have you changed any local administering agencies in the last year?
Yes
No
8.9 If so, why?
Agency was in noncompliance with Grant recipient requirements for LIHEAP -
Agency is under criminal investigation
Added agency
Agency closed
Other - describe
8.10 If a subrecipient is no longer providing LIHEAP, are you aware of prior-year LIHEAP funds being mismanaged or misspent?
No
Yes
8.10a If yes, please explain.
8.10b If you are aware, were other federal programs impacted such as CSBG, SSBG, Head Start, TANF, and Department of Energy
Weatherization funding, etc.
Yes
No
8.10c If yes, please explain.
If any of the above questions require further explanation or clarification that could not be made
in the fields provided, attach a document with said explanation here.
Page 20 of 47
Section 9 - Energy Suppliers,, 2605(b)(7) - Assurance 7
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 9: Energy Suppliers, 2605(b)(7) - Assurance 7
9.1 Do you make payments directly to home energy suppliers?
Heating
Yes
No
Cooling
Yes
No
Crisis
Yes
No
Are there exceptions?
Yes
No
If yes, Describe.
9.2 How do you notify the client of the amount of assistance paid?
We call the client and send a letter.
9.3 How do you assure that the home energy supplier will charge the eligible household, in the normal billing process, the difference between the
actual cost of the home energy and the amount of the payment?
Letter to the vendor that states the approved benfit amount.
9.4 How do you assure that no household receiving assistance under this title will be treated adversely because of their receipt of LIHEAP
assistance?
Promote reporting of incidents.
9.5. Do you make payments contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible
households?
Yes
No
If so, describe the measures unregulated vendors may take.
Attach a copy of the template statewide vendor agreement or a policy that indicates local agreements must adhere to statewide policies and
assurances.
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 21 of 47
Section 10 - Program, Fiscal Monitoring, and Audit, 2605(b)(10) - Assurance 10
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Clearance No.: 0970-013
Expiration Date: 02/28/2027
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 10: Program, Fiscal Monitoring, and Audit, 2605(b)(10)
10.1. How do you ensure good fiscal accounting and tracking of funds?
Contacted financial accounting firm and utilize accounting software to process all transactions. All budgets and expenditures are entered
into the accounting software and operated by our tribal finance staff.
10.1a Provide your definitions of the following:
Obligation
What we obligate to pay for the client based off their intake.
Expenditures
What we pay for the client.
Expenditure timeframe
Administrative costs
Indirect Costs.
Audit Process
10.2. Is your LIHEAP program audited annually under the Single Audit Act and OMB Circular A - 133?
Yes
No
10.2a - if yes, describe your auditor selection process.
10.3. Describe any audit findings of the grant recipient (i.e. State/Tribe/Territory) rising to the level of material weakness or reportable condition
cited in the single audits, inspector general reviews, or other government agency reviews from the most recently audited fiscal year.
No Findings
Finding
Type
Brief Summary
Resolved?
Action Taken
1
10.4. Audits of Local Administering Agencies
What types of annual audit requirements do you have in place for local administering agencies/district offices?
Select all that apply.
Local agencies/district offices are required to have an annual audit in compliance with Single Audit Act and OMB Circular A-133
Local agencies/district offices are required to have an annual audit (other than A-133)
Local agencies/district offices' A-133 or other independent audits are reviewed by Grant recipient as part of compliance process.
Grant recipient conducts fiscal and program monitoring of local agencies/district offices
Local agencies and district offices are required to have an annual audit in compliance with Single Audit Act and OMB Circular A-133
Compliance Monitoring
10.5. Describe your monitoring process for compliance at each level below. Check all that apply.
Grant recipients have a policy in place for appropriate separation of duties and internal controls.
Internal program review
Departmental oversight
Secondary review of invoices and payments
Page 22 of 47
Other program review mechanisms are in place. Describe:
Local Administering Agencies/District Offices:
On - site evaluation
Annual program review
Monitoring through central database
Desk reviews
Client File Testing/Sampling
Other program review mechanisms are in place. Describe:
10.6 Explain, or attach a copy of your local agency monitoring schedule and protocol.
10.7. Describe how you select local agencies for monitoring reviews. Attach a risk assessment if subrecipients are utilized.
Site Visits:
Desk Reviews:
10.8. How often is each local agency monitored? Please attach a monitoring schedule if one has been developed.
10.9. How many local agencies are currently on corrective action plans?
If any of the above questions require further explanation or clarification that could not be made in
the fields provided, attach a document with said explanation here.
Page 23 of 47
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.