Page 36

Official source

Section 14 - Leveraging Incentive Program ,2607A 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 14:Leveraging Incentive Program, 2607(A)

14.1 Do you plan to submit an application for the leveraging incentive program?

Yes No

14.2 Describe instructions to any third parties and/or local agencies for submitting LIHEAP leveraging resource information and retaining records.

14.3 For each type of resource and/or benefit to be leveraged in the upcoming year that will meet the requirements of 45 C.F.R. § 96.87(d)(2)(iii), describe the following: Resource What is the type of resource or benefit ? What is the source(s) of the resource ? How will the resource be integrated and coordinated with LIHEAP? 1

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 34 of 55

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Page 36

Official source

Section 14 - Leveraging Incentive Program ,2607A 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 14:Leveraging Incentive Program, 2607(A)

14.1 Do you plan to submit an application for the leveraging incentive program?

Yes No

14.2 Describe instructions to any third parties and/or local agencies for submitting LIHEAP leveraging resource information and retaining records.

14.3 For each type of resource and/or benefit to be leveraged in the upcoming year that will meet the requirements of 45 C.F.R. § 96.87(d)(2)(iii), describe the following: Resource What is the type of resource or benefit ? What is the source(s) of the resource ? How will the resource be integrated and coordinated with LIHEAP? 1

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 34 of 55