Online Data Collection (OLDC) System Instructions for Low Income Home Energy Assistance Program (LIHEAP) Model Plan Submission

How to Use the Clone Report Feature in OLDC to Submit a New FY26 LIHEAP Model Plan

The Clone Report feature in OLDC allows the user to populate the fields of a current year’s form with the data from a prior year’s form. Follow the steps below to copy all information from your FY25 Model Plan into your FY26 Model Plan.

Step 1: Log into GrantSolutions, then select OLDC at the top right side of the screen. Click on the Report Form Entry link at the top left of the screen.

Step 2: This will take you to the Program and Grantee Selection screen.

In the Program Name dropdown box, select Low Income Home Energy Assistance.

In the Grantee Name dropdown box, select the grantee name.

In the Report Name dropdown box, select Model Plan (ACF-122).

Step 3: Click on the button located under Actions. The reporting period is

10/1/2025 – 9/30/2026. This is the FY26 LIHEAP Model Plan reporting period.

Step 4: Once you’ve clicked the button it will take you to the Clone Report screen.

Select the radio button next to 10/1/2024 - 9/30/2025. This is your FY25 Model Plan and it is the information that you want to copy to your FY26 Model Plan. NOTE: The FY25 Model Plan must be in report status “Submission Accepted by CO” to clone to the current year.

Click the “Clone” button.

Step 5: If you’ve followed the above steps properly, you will see a popup message indicating that your report has been cloned successfully. Click the OK button and your FY26 Model Plan will come up with all the information from the FY25 Model Plan prepopulated.

Step 6: Go through every section and enter and update the information to reflect the program for FY26. Pay special attention to dates and figures.

Step 7: Add any required attachments, such as the updated benefit matrix reflecting the 2025 Federal Poverty Guidelines (FPG) or State Median Income (SMI) Estimates mandatory for use in FY26.

Step 8: After all desired sections have been revised and saved, select the Validate option at the top of the report. Fix any errors that are flagged and continue to select Validate until there are no errors.

Step 9: Select the Report Sections dropdown menu listed at the top left of the screen. Select Mandatory Grant Application SF-424. Scroll to the bottom of the SF-424 and select Click to Sign. This action certifies the plan. Select the Report Form Status option at the top left of the screen.

Step 10: Click Submit. This is the final act of submission of your LIHEAP Plan to OCS.

Low Income Home Energy Assistance Program (LIHEAP) LIHEAP Model Plan Reference Guide

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Table of Contents Introduction to the LIHEAP Model Plan ........................................................................................................ 4 General Information (Mandatory Grant Application – SF-425) .................................................................... 6 Section 1: Program Components .............................................................................................................. 8 Types of Assistance ............................................................................................................................... 8 Funding Allocation ................................................................................................................................ 8 Categorical Eligibility ............................................................................................................................. 9 SNAP Nominal Payments .................................................................................................................... 10 Determination of Eligibility ................................................................................................................. 11 Application Process ............................................................................................................................. 11 Section 2: Heating Assistance ................................................................................................................. 12 Section 3: Cooling Assistance .................................................................................................................. 14 Section 4: Crisis Assistance ..................................................................................................................... 15 Section 5: Weatherization Assistance ..................................................................................................... 17 Section 6: Outreach ................................................................................................................................ 18 Section 7: Coordination .......................................................................................................................... 19 Section 8: Agency Designation ................................................................................................................ 20 Section 9: Energy Suppliers ..................................................................................................................... 21 Section 10: Program, Fiscal Monitoring, and Audit ................................................................................ 22 Section 11: Timely and Meaningful Public Participation ........................................................................ 24 Section 12: Fair Hearings ........................................................................................................................ 25 Section 13: Reduction of Home Energy Needs ....................................................................................... 26 Section 14: Leveraging Incentive Program ............................................................................................. 27 Section 15: Training ................................................................................................................................ 28 Section 16: Performance Goals and Measures ....................................................................................... 29 Section 17: Program Integrity ................................................................................................................. 30 Fraud Reporting Mechanisms ............................................................................................................. 30 Identification Documentation Requirements ..................................................................................... 30 Protection of Privacy and Confidentiality ........................................................................................... 30 Section 18: Certification Regarding Debarment, Suspension, and other Responsibility Matters .......... 31 Section 19: Certification Regarding Drug-free Workplace Requirements .............................................. 32 Section 20: Certification Regarding Lobbying ......................................................................................... 33 Section 21: Assurances ........................................................................................................................... 34

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Plan Attachments .................................................................................................................................... 35 GrantSolutions and OLDC ....................................................................................................................... 36 Access the LIHEAP Model Plan Form ...................................................................................................... 37 Navigating the LIHEAP Model Plan ......................................................................................................... 38 Cloning a Report...................................................................................................................................... 39 References .................................................................................................................................................. 41

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Introduction to the LIHEAP Model Plan

Your annual Model Plan addresses each part of the Low Income Home Energy Assistance Program (LIHEAP) lifecycle (see Figure 1).

Figure 1: LIHEAP Lifecycle

Grant recipients use their LIHEAP Model Plans to:

• Submit the funding application required under Sections 2605(a)(1) and (c)(1) of the LIHEAP statute • Provide assurances to the U.S. Department of Health and Human Services (HHS) that they will administer the LIHEAP grant in accordance with federal LIHEAP statutes, rules, and regulations • Outline the LIHEAP components for consistent, accurate, and timely provision to household applicants • Set clear guidelines to which recipients and LIHEAP staff can be held accountable • Ensure that recipients are being treated fairly • Train new staff easily and efficiently • Assist during staff and management transitions • Comply with HHS program integrity and other fiscal requirements

Unless a different due date is announced, to receive LIHEAP funds, your LIHEAP Model Plan must be submitted in the Online Data collection (OLDC) system by September 1.

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Your LIHEAP Model Plan may have up to 21 sections. These sections address the various aspects of program and fiscal administration requirements in the LIHEAP statute, including monitoring, training, and other activities.

Keep the following points in mind when developing your LIHEAP Model Plan:

• Only include information in sections that are applicable to your LIHEAP program. • Some sections are only required for state grant recipients. These sections are marked in the section’s title. • Within each section, there are several questions that should be answered. Most questions are required. Those questions that are not required are noted as optional.

➢ Your Model Plan must be an up-to-date reflection of how your LIHEAP program operates.

➢ Your Model Plan must be consistent with your policy manual.

➢ You should not include facets of the program that you do not plan to administer.

➢ If you need to modify your LIHEAP Model Plan at any point in the federal Fiscal Year (FY), you can submit a revision in OLDC.

This reference guide highlights some of the most relevant questions to address within each of these sections, as well as additional items to think about when creating your Model Plan. This guide will not review every question in the LIHEAP Model Plan. You are encouraged to reach out to your assigned program specialist as you complete your plan with questions or to seek further clarification.

➢ Within each section of the OLDC, be aware of statutes that apply (if any) to each item in the section (e.g., Section 1 Program Components, 2605(a), 2605(b)(1) – Assurance 1, 2605 (c)(1)(C), etc.).

➢ Statutes are listed above applicable items in each section.

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General Information (Mandatory Grant Application – SF-425) This Section is required for all LIHEAP Model Plan

The first part of your LIHEAP Model Plan outlines basic information about you (the grant recipient) and your Model Plan. Pay close attention to the information you provide in the following parts.

➢ Name and contact information of person to be contacted on matters involving this application

The information in this part should match your grant recipient contact information posted on the Office of Community Services (OCS) website (see Figure 2). If it does not, contact OCS to ensure corrections are made to the website.

Figure 2: Contact Information

➢ Applicant

Your congressional district is the area in which your main office is located. Be sure to cross-check this location with the address listed in part 7b Address. The Congressional District Locator by ZIP Code can be found at: My Congressional District (census.gov).

For question 8, if you are a Tribal Consortium please include the information requested in Figure 3.

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Figure 3: Type of Applicant

➢ Authorized Certifying Official

The name or title of the authorized certifying official should match the information provided in the Delegation Letter. Otherwise, it should be the name of your grant recipient’s Governor or Tribal Chairperson.

If the Delegation Letter is from a prior year, cross-check the name you provide with the name of current Governor or Tribal Chairperson in the appropriate directory: • U.S. Governors Directory: National Governors Association (nga.org) • Tribal Chairperson Directory: Tribal Leaders Directory | Indian Affairs (bia.gov)

See the reference section of the guide for example Delegation Letters

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Section 1: Program Components This Section is required for all LIHEAP Model Plans

Types of Assistance First, you need to identify the types of assistance that will be covered under your LIHEAP Model Plan:

• Heating • Cooling • Weatherization • Sumer Crisis Assistance • Winter Crisis Assistance • Year-Round Crisis Assistance • Assurance 16

You are required to include either a heating or cooling program. You may choose to include both programs. You are also required to include a crisis program. The weatherization program and Assurance 16 are always optional. Even if you do not initially include a type of assistance, you can revise your Model Plan in the OLDC after it is approved.

The start and end dates of operation for each component should span no more than 12 months (typically between October 1 and September 30) of the FY of your LIHEAP Model Plan. If you intend to issue crisis benefits for winter only, the dates of operation should not extend into the summer months. A year-round crisis program should show dates of operation that span an entire year. Grant recipients may choose different start and end dates for their programs within the FY covered by the LIHEAP Model Plan.

The end date for the winter crisis component cannot be before March 16. The LIHEAP statute requires that crisis funds be made available at least through March 15.

Funding Allocation After you identify the types of assistance you will provide, you will need to estimate the percentage of funds used for each area of operation. When you add the percentages, it should always equal 100 percent (see Table 1). Prior year totals will prepopulate so that you can compare what was estimated in the previous FY.

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Table 1: Funding Allocation Example

Percentage Area of Operation Maximum Allocations 50% Heating Assistance N/A 10% Cooling Assistance N/A 10% Summer Crisis Assistance* N/A 10% Winter Crisis Assistance* N/A 0% Year-Round Crisis Assistance* N/A 0% Weatherization The maximum allocation for Weatherization is 15% of the total allocation. After March 31st of each year, grant recipients may request a waiver from OCS to transfer a maximum of up to 25%. If you receive a waiver, revise this information in your LIHEAP Model Plan in OLDC to account for the added percentage in Weatherization, as well as the reduction from the area you plan to take those funds. For additional details to include in the waiver request, review the LIHEAP - Code of Federal Regulations. 5% Carryover to the Following FY The maximum allocation is up to 10% from the current year. 10% Administrative and Planning Costs The maximum allocation is up to 10% of the total allocation. 5% Services to Reduce Home Energy Needs (Assurance 16) The maximum allocation is up to 5% of the total allocation.

0% Development and Implementation of Leveraging Activities State Grant recipients: The maximum allocation is the greater of 0.08% or $35,000. Tribal Grant recipients: The maximum allocation is the greater of 2% or $100. Crisis Funding must be available for crisis assistance until March 15. If the funding allocation percentage for crisis does not appear sufficient, OCS may require additional details from you prior to approval.

The percentages listed in Table 1 are examples only. Grant recipients should create a funding allocation that utilizes their LIHEAP award in the most effective way. The OCS anticipates change in the allocations initially submitted. If your estimated allocations begin to vary from your LIHEAP Model Plan, submit a revision to your plan in the OLDC by September 30 of the fiscal year. OCS encourages you to revise your Model Plan as often as needed and as early as possible.

Categorical Eligibility Categorical eligibility is used to automatically income qualify households for LIHEAP if at least one member currently receives assistance from another program.

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➢ 1.4 a. 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.

If you intend to adopt categorical eligibility, this part of Section 1 asks you to identify when households or individuals are categorically eligible based on other programs in which they participate.

Eligible programs according to the LIHEAP statute include the following:

• Temporary Assistance for Needy Families (TANF) • Supplemental Security Income (SSI) • Supplemental Nutrition Assistance Program (SNAP) • Certain Means-tested Veterans Programs

➢ 1.5 Do you automatically enroll households without a direct annual application?

If you do not require a direct annual application from each customer, be sure to provide responses in the explanation field to describe how applicants are made eligible each year through identity and household composition documentation or verification. Answering the following questions would provide OCS with an explanation of your process:

• How are customers informed of their fair hearing rights? • How is income eligibility established? • If eligibility is established through categorical eligibility, how is their level of income determined to make a benefit determination? • How is each customer’s utility information identified?

SNAP Nominal Payments There is a provision in the Farm Bill that allows a SNAP recipient to receive a higher level of benefit if the recipient also received LIHEAP. Some states decide to provide a nominal LIHEAP benefit of greater than $20, the minimum threshold established in the Farm Bill. This question is asking you to justify the nominal benefit amount, apart from the fact that it would result in greater SNAP benefits. Keep in mind that LIHEAP funds must support home energy costs or needs.

You have the discretion to choose either gross pay or net pay as the basis for determining income eligibility.

State grant recipients that select net pay should report on each customer’s income level based on gross pay in the Household Report Long Form. States must record the household's gross pay, even if that amount is not used for income eligibility purposes.

This stipulation does not apply to Tribal grant recipients who report on the short form.

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You need to identify what you will consider as countable income for the household when determining LIHEAP eligibility. This part of the section provides a list of options that you may want to take into consideration.

Some of the most considered types of income include the following:

• Social Security Administration (SSA) benefits (including or excluding Medicare deduction) • Retirement • Earned income of a child under the age of 18 (student or not a student) • Unemployment • Alimony

The Federal Government does not set a standard for what shall be included as countable income for LIHEAP eligibility determinations.

Therefore, in your LIHEAP Model Plan, please be specific as to what types of income you will count. You may want to consider similarly administered programs to ease customer application burden.

Be aware that there are very specific sources of income that cannot be counted when determining LIHEAP eligibility due to restrictions set into Federal law:

• Supplemental Nutrition Assistance Program (SNAP) benefits • Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits • Free or discounted lunches from the National School Lunch Program • Non-gambling related Tribal per capita payments (up to $2,000 per person per year) • Federal student aid for education (e.g., grants and loans to undergraduates)

Determination of Eligibility Next, you need to define which income threshold, or combination of thresholds* you will be using when determining LIHEAP eligibility:

• 150% of Federal Poverty Guidelines (FPG) • 60% of State Median Income (SMI)

You must cap income eligibility for LIHEAP’s fuel assistance and crisis benefits at: (1) no more than the greatest of 150% of the FPG or 60% of the SMI; and (2) no less than 110% of FPG.

*Note: grant recipients can use a combination of both FPG and SMI thresholds in setting income eligibility criteria.

Application Process

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Questions 1.10-1.13 ask you to describe your application process. If your process differs from the check boxes provided, please describe how you allow customers to apply in the description boxes provided.

Section 2: Heating Assistance This Section is required for all LIHEAP Model Plans if included in Section 1

In this section, you will be asked to consider the following questions and provide answers:

• Do you require an assets test? • Do you have additional or differing eligibility policies for renters or homeowners? • Do you give priority to older adults, individuals with a disability, young children, or households with high energy burdens? • What variables will you use to determine benefit levels? • What are the minimum and maximum benefits, and does this include in-kind benefits (e.g., blankets, space heaters, fans, etc.)?

➢ 2.3 Check the appropriate boxes below and describe the policies for each.

If you respond “yes” to any questions for 2.3, you must describe the differing eligibility policy. Understanding why there are differing eligibility criteria will help OCS to ensure Assurance 2 is met.

➢ 2.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.

Vulnerable populations include adults 60 years of age or older, individuals with a disability (defined by you as the grant recipient), and children under the age of 6.

Prioritizing vulnerable households is not required, but OCS encourages prioritizing these households as it helps to target benefits to those in the greatest need.

➢ 2.5 Check the variables you use to determine your benefit levels.

If you check the variables below, those variables must also be included in your attached benefit matrix. Your benefit matrix should include income, household size, and energy cost or need. The uploaded benefit matrix should use the most recently published income guidelines. The guidelines can be found on the OCS LIHEAP Policy and Guidance webpage.

You can define the variable to demonstrate that home energy costs or needs are considered. Fuel type is commonly used to demonstrate energy need. Some Tribes also consider the vulnerable status of a household member as the energy need, which is not encouraged but is allowable. Example benefit payment matrices and calculations can be found on the LIHEAP Clearinghouse.

➢ 2.6 Describe estimated benefit levels for the fiscal year for which this plan applies.

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Make sure the minimum and maximum benefit levels listed in your LIHEAP Model Plan match what is included in the uploaded benefit matrix.

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Section 3: Cooling Assistance This Section is required for all LIHEAP Model Plans if included in Section 1

In this section, you will be asked to consider the following questions and provide answers:

• Do you require an assets test? • Do you have additional or differing eligibility policies for renters or homeowners? • Do you give priority to older adults, individuals with a disability, young children, or households with high energy burdens? • What variables will you use to determine benefit levels? • What are the minimum and maximum benefits, and does this include in-kind benefits (e.g., blankets, space heaters, fans, etc.)?

➢ 3.3 Check the appropriate boxes below and describe the policies for each.

If you respond “yes” to any questions for 2.3, you must describe the differing eligibility policy. Understanding why there are differing eligibility criteria will help OCS to ensure Assurance 2 is met.

➢ 3.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.

Vulnerable populations include adults 60 years of age or older, individuals with a disability (defined by you as the grant recipient), and children under the age of 6.

Prioritizing vulnerable households is not required, but OCS encourages prioritizing these households as it helps to target benefit to those in the greatest need.

➢ 3.5 Check the variables you use to determine your benefit levels.

If you check the variables below, those variables must also be included in your attached benefit matrix. Your benefit matrix should include income, household size, and energy cost or need. The uploaded benefit matrix should use the most recently published income guidelines. The guidelines can be found on the OCS LIHEAP Policy and Guidance webpage.

You can define the variable to demonstrate that home energy costs or needs are considered. Fuel type is commonly used to demonstrate energy need. Some Tribes also consider the vulnerable status of a household member as the energy need, which is not encouraged but is allowable. Example benefit payment matrices and calculations can be found on the LIHEAP Clearinghouse.

➢ 2.6 Describe estimated benefit levels for the fiscal year for which this plan applies.

Make sure the minimum and maximum benefit levels listed in your LIHEAP Model Plan match what is included in the uploaded benefit matrix.

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Section 4: Crisis Assistance This Section is required for all LIHEAP Model Plans

Section 4 asks similar questions as Sections 2 and 3 and provides additional opportunity to describe how crisis benefits are administered.

• Provide your LIHEAP program's definition for determining a crisis. If you administer multiple crisis assistance programs (i.e., winter, summer, or year-round), include all program definitions. • What is considered a “life-threatening crisis”? • Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? • Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening situations?

Keep in mind that “crisis” and “life-threatening crisis” must be defined separately because they have different response times: 48 hours for a crisis and 18 hours for a life-threatening crisis.

• These definitions need to be different enough so that an intake worker is easily able to determine how to apply the crisis definition and how to apply the life-threatening crisis definition. • These definitions need to be objective enough so that they can be fairly applied throughout your entire service area. • These definitions should be specific enough so that the conditions and intervention timeframes for each crisis type can be documented in a customer file.

➢ 4.8 How do you handle crisis situations?

Decide how your crisis program will be designed:

• Separate Component: This process involves a separate application and, often, a different benefit level than heating or cooling assistance. • Benefit Fast Track: No separate amount of crisis funds is issued. Rather, benefits are issued to crisis customers within crisis response time frames. • Other: Be specific as to how you intend to handle crisis situations.

➢ 4.9 If you have a separate component, how do you determine crisis assistance benefits?

If you have selected “amount to resolve the crisis,” this implies up to a maximum amount. It also implies there is not a separate crisis component matrix.

➢ 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?

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➢ 4.11 Do you provide individuals with a disability the means to submit an application for crisis benefits without leaving their home?

A “No” response to 4.10 and 4.11 requires an explanation. You must provide alternative intake processes of homebound individuals or individuals with a disability, as well as ensure that services are geographically accessible.

➢ 4.12 Indicate the maximum benefit for each type of crisis assistance offered.

Verify that your responses here align with the dates of operation for the crisis component in Section 1.1.

• If you issue benefits for crisis during winter only, the dates of operation should not extend into what you consider to be the summer months. • If you issue benefits for crisis during summer, the dates of operation should include what you consider to be the summer months. • A year-round program should show dates of operation that span an entire year. You do not need to separate crisis benefits for winter and summer.

➢ 4.14 Do you provide for equipment repair or replacement using crisis funds?

Verify that your response here aligns with your response in 4.7 regarding non-working heating or cooling equipment. When a maximum benefit is under $1,000, OCS may ask if the maximum benefits provided are reasonable to cover equipment repair or replacement.

➢ 4.15 Check appropriate boxes below to indicate type(s) of assistance provided.

Verify your responses here regarding the type(s) of assistance provided in question 1.1 and the maximum benefit in question 4.12.

If providing equipment repair and replacement under crisis assistance, ensure that your policies comply with crisis assistance policies by meeting the 18-hour or 48-hour timelines. Your policies must also account for availability of interventions while processing the pre-inspection of any repair or replacement.

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Section 5: Weatherization Assistance This Section is required for all LIHEAP Model Plans if included in Section 1

In this section, you will be asked to consider the following questions and provide answers:

• Do you require an Assets test? • Do you have additional or differing eligibility policies for renters than homeowners? • Do you give priority to older adults, individuals with a disability, young children, or households with high energy burdens? • Do you use and Average Cost per Unit (ACPU)? • What are the minimum and maximum benefits, and does this include in-kind benefits (e.g., blankets, space heaters, fans, etc.)? • Who is implementing the weatherization program? • Is there a separate monitoring protocol for weatherization? • What rules are used: Department of Energy (DOE), LIHEAP, or a mix? • What weatherization measures do you provide?

➢ 5.1 Designate the income eligibility threshold used for the Weatherization component.

If you are operating your program entirely under DOE Weatherization Assistance Program (WAP) rules or mostly under DOE rules, you can indicate the income eligibility up to 200% of the FPL (the eligibility threshold for WAP) for weatherization.

➢ 5.4 Is there a separate monitoring protocol for weatherization?

If you selected “Yes” in 5.2 and “No” in 5.4, you may be contacted by OCS so that you can further explain how your weatherization program is monitored.

➢ 5.7 Do you have additional or differing eligibility policies for renters, renters living in subsidized housing, or renters with utilities included in the rent?

If you selected “No” to either of these questions about eligibility requirements for renters, you may be contacted by OCS so that you can further explain how you will ensure you have the permission of the landlord to do the work on a rented unit.

If receiving such permission of the landlord is a requirement, select “Yes” to these questions.

➢ 5.11 What LIHEAP weatherization measure do you provide?

Check the categories that apply, including rooftop solar and community solar projects.

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Section 6: Outreach This Section is required for all LIHEAP Model Plans

Outreach is an important part of a successful LIHEAP Model Plan. This section asks you to identify types of outreach activities you will conduct to ensure eligible households are made aware of all available LIHEAP assistance. This includes activities done by you (the grant recipient), as well as any applicable partners, subgrant recipients, utility vendors (using bill inserts), other community partners, or departments within your state, Tribe, or territory.

Examples include the following:

• Posters and flyers • Newspaper articles • Broadcast media announcements • Mailing inserts and brochures • Communication during intakes • Cross-program information for target groups • Web posting, email, texting, events, and social media

If you select “Other” as one of your options, please be sure to specify the other types of outreach you intend to perform.

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Section 7: Coordination This Section is required for all LIHEAP Model Plans

Do you coordinate LIHEAP with other assistance programs available to households with low incomes? Coordination may help streamline the application process. Examples include the following:

• Offering single applications that can be used for multiple programs • Accepting intake referrals to or from other programs • Sharing of an intake center so the customer only has to go to one location

This section provides a lot of examples that you can use; but, if you have other plans, please include those plans at the bottom of the section.

➢ 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.).

If you transfer some of your LIHEAP funds to another agency for weatherization (see 5.2), your response here may describe how activities between the two agencies are coordinated to ensure customers receive services as seamlessly as possible:

• Do the two agencies share subgrant recipients? • Do they exchange lists of eligible customers? • Is there a weatherization referral check box on the LIHEAP application?

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Section 8: Agency Designation This Section is required for State grant recipients and the Commonwealth of Puerto Rico

This section of the LIHEAP Model Plan asks you to describe the roles and responsibilities for LIHEAP administration. Questions include:

• How would you categorize the primary responsibility of your state agency? • How do you provide alternate outreach and intake (if you are a welfare agency) for heating, cooling, and crisis assistance? • Who determines customer eligibility? • Who processes benefit payments? • Who performs installation of weatherization measures?

If you utilize subgrant recipients or local administering agencies, you must attach a list of agencies that includes their name, address, phone number, county(-ies) served, congressional district, and UEI number. This information will be utilized by OCS to ensure customers seeking assistance are provided the appropriate contact information when using the “Do I Qualify?” tool on the LIHEAP Clearinghouse.

➢ 8.6 What is your process for selecting local administering agencies?

This question asks you to include a description of your formal subgrant recipient or local administering agency selection process. Many states sub-grant to the same local agencies because the state has a legislative exemption or state regulations identify local agencies.

Having a plan for how subgrant recipients are selected can be helpful in the event an agency closes or is no longer funded through LIHEAP. A plan can ensure continuity of program administration and help to ensure a lack of disruption of service for customers.

Questions 8.8 through 8.10 provide OCS with an understanding of changes, if any, in local subgrant recipient administration. If changes occur, OCS will ensure updates are made to the LIHEAP Clearinghouse and follow up with you regarding any potential compliance areas that may need to be addressed.

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Section 9: Energy Suppliers This Section is required for all LIHEAP Model Plans

When dealing with energy suppliers (vendors), such as utility companies and bulk fuel companies, you will need to determine how payments are made and documented for each type of assistance:

• Is payment made directly to the home energy supplier? • Will there be a confirmation letter for the customer? • How will customers be treated fairly by the utility vendor? • Are funds provided to the customer to pay the bill?

To maintain program integrity, it is recommended to pay the energy supplier and not the customer, whenever possible.

➢ 9.2 How do you notify the customer of the amount of assistance paid?

You are required to notify customers of their receipt of benefits and the amount (or their denial of services). Notification can be done in writing after the fact or verbally during the intake process. If you enroll customers automatically without an application, your response to this question should address how those customers are notified. Within your response, include the specific timeframe in which you will provide notification to your customers.

➢ 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?

➢ 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?

Your response to these questions should reference stipulations in a vendor agreement. Please ensure these stipulations are specific and measurable; try not to use vague statements as this may require additional clarification.

The final request of this section asks that you attach a copy of the template statewide vendor agreement or a policy that indicates local agreements must adhere to statewide policies and assurances.

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Section 10: Program, Fiscal Monitoring, and Audit This Section is required for all LIHEAP Model Plans

This section asks what types of audits or compliance reviews you, as the grant recipient, receive throughout the year and what types of monitoring practices you will be using. Consider questions such as:

Will your LIHEAP program be audited annually under the Single Audit Act and OMB Circular A - 133?

• What types of annual audit requirements will you have in place for local administering agencies or district offices?

How will you monitor compliance with the policies and procedures?

• Internal program and fiscal reviews? • File sampling? • Monitoring through central database?

Do you have corrective action plans in place?

• Do you have any subgrant recipients currently on a corrective action plan?

What is your monitoring schedule and protocol?

• If you do not monitor 100% of your subgrant recipients, how many do you intend to monitor in the FY for this LIHEAP Model Plan, and what does that schedule look like? • What is your risk assessment process? • What methods do you use to monitor your subgrant recipients?

Administration of LIHEAP funds will need to be monitored in compliance with the Uniform Administrative Guidance (UAG) issued by the Office of Management and Budget (OMB).

➢ 10.1 How do you ensure good fiscal accounting and tracking of funds? Be specific about tracking of grant award, tracking of expenditures, tracking vendor (benefit) refunds, fiscal reporting process, and fiscal software systems being used.

Responses to this question should include the following:

• How you track subgrant recipient awards to ensure that funds are expended within the allowable contractual period • How you track funds obligated by a second agency or department when funds are transferred for weatherization (states only) • How you track vendor refunds • How you track the obligation of funds

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• How you track the separation of funding line items by component (e.g., crisis, heating, weatherization, etc.) and by FY

Question 10.1a asks you to provide your definition for obligation, expenditure timeframe, and administrative costs. These definitions should be consistent with other federal grants you may receive and should be applied to LIHEAP in the same way you apply the definitions to your own funds.

➢ 10.2 Is your LIHEAP program audited annually under the Single Audit Act and OMB Circular A - 133?

All grant recipients (states, territories, and tribes) receiving $750,000 or more in federal funds in a single year are required to submit a Single Audit.

➢ 10.3 Describe any audit findings rising to the level of material weakness or reportable condition cited in the A-133 audits, grant recipient monitoring assessments, inspector general reviews, or other government agency reviews of the LIHEAP agency from the most recently audited fiscal year.

Any findings you list may prompt a conversation with OCS to discuss the actions taken to resolve the issues. To help alleviate the need for such a discussion, try to add sufficient details in the Action Taken column for each item you list.

➢ 10.7 Describe how you select local agencies for monitoring reviews. Attach a risk assessment if subrecipients are utilized.

Be as specific as possible when explaining how you determine monitoring for site visits and desk reviews.

Requirements of the OMB Uniform Administrative Guidance stipulate that grant recipients must perform a risk assessment of subgrant recipients in order to determine the appropriate level or type of monitoring.

➢ 10.9 How many local agencies are currently on corrective action plans?

Be aware that if you list any number other than zero, you may be contacted by OCS to discuss monitoring and training or technical assistance provided to the subgrant recipients in question. To help alleviate the need for such a discussion, you can use the space at the bottom of this section to provide more information.

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Section 11: Timely and Meaningful Public Participation This Section is required for all LIHEAP Model Plans

In this section, you will identify how you obtained input from the public in the development of your LIHEAP Model Plan. By providing the public an opportunity to comment, you are not only meeting the statutory requirements, but you are also ensuring the program is designed to meet local needs. You will select all opportunities provided as listed below:

• Public hearing(s) – Required for States • Tribal Council meeting(s) • Draft Model Plan posted to the website and available for comment • Hard copy of Model Plan available for public view (e.g., newspapers, newsletters, radio via public service announcements) and comment • Request for comments from applicants are recorded • Stakeholder consultation meeting(s) • Comments are solicited during outreach activities • Other

• State grant recipients are required to hold public hearings, which use a formal process to obtain feedback from the community.

• Tribes and territories are not required to hold public hearings, but they are required to solicit public participation.

Public participation must occur prior to the submission of your LIHEAP Model Plan. Ensure there is sufficient time for the public to review and comment on the LIHEAP Model Plan before submission. Avoid holding a public hearing one week before the plan submission, as that is likely not enough time to consider any comments received and use this information to modify your plan.

➢ 11.5 What changes did you make to your LIHEAP Model Plan as a result of public participation and solicitation of input?

The response to this question allows you to show the public how you listened to and responded to their input and allows OCS to better understand why you have elected to administer your program.

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Section 12: Fair Hearings This Section is required for all LIHEAP Model Plans

The LIHEAP statute requires that you have a process in place for fair hearings. When an application is denied or not processed in a timely manner, the applicant has the right to appeal. How do you inform applicants of their right to an appeal?

• Pamphlets • Described in their LIHEAP applications • Posters in the intake office • Included in their approval or denial letters (must not be the only communication of rights)

• Customers must be made aware of their appeal rights before the application is processed. •

• Printing appeal rights on only the approval or denial letters does not meet the requirements of the LIHEAP statute because applicants are not given enough opportunity to appeal when their applications are not processed in a timely manner or if they are not otherwise satisfied with the outcome of the application.

Be clear as to what the applicants must do as part of the appeal process. Explicitly outline the information that will be required as part of the appeal process:

• What must the applicant do to appeal, and in what time frame? • Under what circumstances can an applicant appeal? • What are the procedures for an appeal process? (How do they get this information?)

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Section 13: Reduction of Home Energy Needs This Section is required for all LIHEAP Model Plans if you included these activities in Section 1

Assurance 16 activities are used to reduce home energy needs. This section asks you to describe how you will use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and, thereby, the need for energy assistance. Be sure to identify the impact you hope these activities will make.

If you included Assurance 16 activities in the prior year’s Model Plan, identify the impact those activities had, how those outcomes were achieved, and how many households were served. There are many ways the impact of the Assurance 16 program can be measured.

➢ 13.3 Describe the impact of such activities on the number of households served in the previous Federal FY. Impact can be measured in many different ways: using logic models, data tracking systems, process evaluation, impact evaluation, number of households served versus applied, and performance management for example.

When you provide a description of the impact of the services, be sure to include more than just the number of households served:

• What difference did the services make in the life of the customer? • What were you trying to accomplish with your Assurance 16 activities? • How did you measure your success?

Outreach activities to promote LIHEAP and recruit applicants for LIHEAP assistance are not allowable under Assurance 16. For additional examples, please contact your liaison to complete this section.

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Section 14: Leveraging Incentive Program This Section is not required, but is encouraged

The purpose of this section is to prepare, or allow the grant recipients to plan, for the Leveraging Incentive grant application for the following federal fiscal year. If HHS decides to fund the Leveraging Incentive grant program in the following federal fiscal year, but you have not completed this section of your model plan, you may not qualify for a Leveraging Incentive grant. Grant recipients are usually requested to submit a separate form to be considered for the Leveraging Incentive grant.

Collaboration with other programs could help leverage non-federal resources to best service the customers:

• Do you plan to submit an application for the leveraging Incentive program? • What non-federal resources do you plan to leverage with LIHEAP? • What are your instructions to third parties or local agencies for submitting LIHEAP leveraging resource information and retaining records?

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Section 15: Training This Section is required for all LIHEAP Model Plans

Training (one-on-one or in a group setting) is a vital part of your LIHEAP Model Plan that outlines how policies and procedures are communicated for the following:

• Grant recipient staff • Local agencies and subgrant recipients (state grant recipients only) • Utility vendors

➢ 15.2 Does your training program address fraud reporting and prevention?

Selecting “No” may prompt a conversation with OCS to discuss how you make your staff, subgrant recipients, or vendors aware of how to detect, prevent, and report fraud, waste, and abuse. To help alleviate the need for such a discussion, you can use the space at the bottom of this section to provide more information.

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Section 16: Performance Goals and Measures This Section is required for all State LIHEAP Model Plans

➢ 16.1 Describe your progress toward meeting the data collection and reporting requirements of the four required LIHEAP performance measures. Include timeframes and plans for meeting these requirements and what you believe will be accomplished in the coming federal fiscal year.

If needed, contact your assigned program specialist for technical assistance.

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Section 17: Program Integrity This Section is required for all LIHEAP Model Plans

To prevent fraud, verification is extremely important. This section asks you for information about the practices you have in place to prevent fraud, waste, and abuse. It asks about how you verify the identities of customers, as well as the validity of vendors, and how you ensure this information is accurate.

Fraud Reporting Mechanisms Describe what is available to the public to report suspected cases of waste, fraud, and abuse. • Online fraud reporting • Dedicated fraud reporting hotline • Report directly to local agency, district office, or grant recipient office • Report to state inspector general or attorney general • Forms and procedures in place for local agencies, district offices, and vendors to report fraud, waste, and abuse • Posted in local administering agencies offices • Other - Describe:

Identification Documentation Requirements How do you verify that customers are legitimately in need of LIHEAP assistance and determine that they are eligible to receive these services? This section allows you to select what type of documentation is required and from whom in the household you will be collecting the documentation.

Be sure to describe any exceptions to the policies you have outlined in this section.

Protection of Privacy and Confidentiality You handle personally identifiable information (PII) on a daily basis. Setting up best practices for privacy protection is crucial for keeping that PII safe and away from those who would use that information for fraudulent purposes. This section asks you to explain how you will keep this PII safe.

If “Other” is selected in this section, be sure to provide a description of the policy. OCS may request additional details to ensure program integrity.

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Section 18: Certification Regarding Debarment, Suspension, and other Responsibility Matters This Section is required for all LIHEAP Model Plans

Thoroughly review and certify by checking the box at the end of the section.

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Section 19: Certification Regarding Drug-free Workplace Requirements This Section is required for all LIHEAP Model Plans

Thoroughly review and certify by checking the box at the end of the section. A complete address for the Place of Performance is required. Do not enter a P.O. Box address in first line.

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Section 20: Certification Regarding Lobbying This Section is required for all State LIHEAP Model Plans

Thoroughly review and certify. This certification is required of all applicants.

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Section 21: Assurances This Section is required for all LIHEAP Model Plans

Thoroughly review and certify by checking the box.

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Plan Attachments This Section is required for all LIHEAP Model Plans The following documents must be attached to this application:

• Delegation Letter is required if someone other than the Governor or Chairman certified this report. • Heating component benefit matrix, if applicable • Cooling component benefit matrix, if applicable • Minutes, notes, or transcripts of public hearing(s)

Optional: Policy Manual Optional: Subrecipient contract Optional: Model Plan Participation notes for Tribes

Always include a Delegation Letter. You may use the same letter from the prior year if everything on the letter (the person or title) remains unchanged and is still applicable. If the Governor or Chairman has changed from last year, you will be required to include a new Delegation Letter.

OCS will not accept your Model Plan if this letter has not been updated to reflect the change in Governor or Chairman. If there is an additional designee to sign or certify the plan, ensure that the letter includes the additional designee.

Tribal grant recipients who are currently working on developing a policy manual may include a draft of the manual as another attachment. Work on your policy manual will NOT be tied to the approval of your Model Plan.

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GrantSolutions and OLDC

To receive LIHEAP funds for the federal fiscal year, your Model Plan must be submitted in the OLDC by September 1 (unless a different due date has been announced). GrantSolutions offers interactive, computer-based trainings that are available on your schedule and are geared to topics associated with grant recipient user accounts. The courses are available on the GrantSolutions Services homepage within the system. The attached flyer provides easy instructions on how to access the trainings.

In addition, OLDC within GrantSolutions has several Frequently Asked Questions (FAQs) and training modules to help grant recipients navigate between different reports and applications. A support Help Desk is available 24 hours a day, seven days a week at (844) 875-6446.

The preferred web browsers to use for accessing the OLDC are Google Chrome or Mozilla Firefox. Use either in compatibility mode.

Additional training material available through GrantSolutions: • Creating an account: Create a login.gov account (grantsolutions.gov) • Getting started with GrantSolutions: Getting Started (grantsolutions.gov) • Training Resources: Recipient GMM Training Resources (grantsolutions.gov)

Once you are logged into your GrantSolutions account, you can click on the graduation cap icon on the top righthand corner of the screen to review interactive trainings.

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Access the LIHEAP Model Plan Form To access the Model Plan form, follow these steps: 1. Click the Report Form Entry hyperlink.

2. Select “Low Income Home Energy Assistance” from the from the Program Name drop-down menu field. 3. Select your grant recipient from the Grantee Name drop-down menu field (if applicable). 4. Select “Model Plan (ACF-122)” from the Report Name drop-down menu field.

After making these three selections, the page will display any previous Model Plans you have submitted or are currently working. 5. You can select one of the existing reports by clicking on the appropriate icon in the Actions column for the corresponding fiscal year. 6. The available options in the Actions column include: a. Revise b. Report Status c. Print Latest Version (HTML) d. View Latest Report e. Clone Report

Note: The clone report option allows you to copy information from a previous LIHEAP Model Plan and use it as the foundation for the plan you intend to submit for the upcoming FY. The clone feature may not be available every year, depending on what changes were made from the prior year.

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Navigating the LIHEAP Model Plan There are a couple of ways to navigate to the various sections of the Model Plan form.

The first way is to select an action from the appropriate drop-down menu for a specific section on the Report Sections page. This will take you directly to that section of the Model Plan form. The second way is to select an option from the Report Sections drop-down menu field. This function is available when you are already on one of the pages for a section of the LIHEAP Model Plan form.

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At the top of each Model Plan form section page, you will see a status bar that indicates where you are in the submission and update process. You also have the following buttons available at the top and bottom of each page: Save, View/Add Attachments, Validate, and Next Section.

Cloning a Report The Clone Report feature in OLDC allows the user to populate the fields of a current year’s form with the data from a prior year’s form. Follow the steps below to copy all information from your current year LIHEAP Model Plan form with the information from a prior year.

This process will only work if you have NOT yet initialized your current FY Model Plan.

If you already started working on the current fiscal year Model Plan, you will need to delete that Model Plan before you can go through the cloning process.

To copy all of the information from your prior federal fiscal year Model Plan into your new federal fiscal year Model Plan, follow these steps:

Step 1: Log into GrantSolutions, then select OLDC at the top right side of the screen. Click on the Report Form Entry link at the top left of the screen.

Step 2: This will take you to the Program and Grantee Selection screen.

A. In the Program Name dropdown box, select Low Income Home Energy Assistance. B. In the Grantee Name dropdown box, select the grantee name. C. In the Report Name dropdown box, select Model Plan (ACF-122).

Step 3: Click on the button located under Actions. The reporting period is 10/1/2025 – 9/30/2026. This is the FY26 LIHEAP Model Plan reporting period.

Step 4: Once you’ve clicked the button it will take you to the Clone Report screen.

A. Select the radio button next to 10/1/2024 - 9/30/2025. This is your FY25 Model Plan, and it is the information that you want to copy to your FY26 Model Plan. NOTE: The FY25 Model Plan must be in report status “Submission Accepted by CO” to clone to the current year.

Step 5: If you have followed the above steps properly, you will see a popup message indicating that your report has been cloned successfully. Click the OK button, and your FY26 Model Plan will come up with all the information from the FY25 Model Plan prepopulated.

If you have followed the above steps properly, you will see a pop-up message indicating that your report has been cloned successfully.

1. Click the OK button.

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2. Your new FY Model Plan will display with all of the information from the prior FY LIHEAP Model Plan already populated. 3. REMEMBER TO SAVE: Once you have completed the cloning process, open any section of your new FY LIHEAP Model Plan and click the Save button at the top of the screen. This will ensure that all the data that has just been transferred into your plan will be saved.

If you close your browser session within the OLDC before saving the information you cloned, you will lose all of the cloned information. When you go back to view your plan, it will be blank. Clicking the Save button in any one of the sections will save the information in all of the sections of your Model Plan.

Even though you have the option to copy your LIHEAP Model Plan from a prior year, you are expected to review every section of the information to ensure the information is up-to-date and as accurate as possible.

Revising a LIHEAP Model Plan in OLDC

This feature allows you to update information in your current year’s Model Plan after it has been submitted. To edit your current FY LIHEAP Model Plan, follow these steps:

1. Log into the OLDC and select the Report Form Entry link on the OLDC Home page to navigate to the Form Selection page to select the Model Plan form. 2. Select the Revise option in the Actions column next to the reporting period dates of your current FY LIHEAP Model Plan. 3. Locate the section you wish to update. 4. Select the appropriate action from the Perform Action drop-down menu field. 5. Make your edits to the section. 6. Click the Save button, located at the bottom of the page.

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References

LIHEAP Fact Sheet: LIHEAP Fact Sheet | The Administration for Children and Families (hhs.gov)

LIHEAP Laws and Regulations: LIHEAP Statute and Regulations | The Administration for Children and Families (hhs.gov)

LIHEAP Action Transmittals, Dear Colleague Notices, and Information Memoranda: LIHEAP Policy and Guidance | The Administration for Children and Families (hhs.gov)

LIHEAP Web Site: Low Income Home Energy Assistance Program (LIHEAP) | The Administration for Children and Families (hhs.gov)

LIHEAP Program Integrity: LIHEAP Program Integrity | The LIHEAP Clearinghouse (hhs.gov)

State Plans, Manuals, and Delegation Letters: LIHEAP State and Territory Plans, Manuals and Delegation Letters | The LIHEAP Clearinghouse (hhs.gov)

LIHEAP Grant recipient Resources: LIHEAP Grant Recipient Resources | The Administration for Children and Families (hhs.gov)

Tribal Plans, Manuals, and Delegation Letters: Tribal Plans, Manuals, Delegation Letters | The LIHEAP Clearinghouse (hhs.gov)

Tribal Statutes and Regulations: Tribal Statutes & Regulations | The LIHEAP Clearinghouse (hhs.gov)

LIHEAP Staff Contacts: LIHEAP Contact Information for the Division of Energy Assistance Federal Staff | The Administration for Children and Families (hhs.gov)

Please note: This document will be made 508 compliant soon.

Mandatory Grant Application SF-424

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- 0075 Expiration Date: 02/28/2027 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 2. Date Received: | State Use Only: 3. Applicant Identifier: 4a. Unique Entity Identifier (UEI) : | 5. Date Received By State: 4b. Federal Award Identifier: | 6. State Application Identifier: 7. APPLICANT INFORMATION *a. Legal Name: *b. Address: *Street 1: | Street 2: *City: | County: *State: | Province: *County: | *Zip/Postal Code: 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 the Notice of Funding Awards and on the U.S. Department of Health and Human Services’ LIHEAP contact list web page): *First Name: | *Last Name: Title: | Organizational Affiliation: *Telephone Number: | Fax Number: *Email: *8. TYPE OF APPLICANT: a. Is the applicant a Tribal Consortium: If yes, please attach at least one of the following documents : Current State-Tribe agreement between their state and the Consortium, signed by the State Chief Executive Officer (such as the Governor or the delegate) and the Consortium President; Consortium letter listing the tribes , signed by the elected Tribal Chief or President of each tribe in the Consortium and signed by the Consortium President; A current resolution letter from each tribe in the Consortium, signed by the elected Tribal Chief or President of that tribe. Each resolution letter needs to state that the Consortium has the tribes’ permission to apply for, and administer, LIHEAP on their behalf and needs to designate a time period for the permission or until rescinded or revoked. Catalog of Federal Domestic Assistance Number | CFDA Title: 9. CFDA NUMBERS AND TITLES 10. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT: 11. AREAS AFFECTED BY FUNDING: 12. CONGRESSIONAL DISTRICTS OF APPLICANT: 13. FUNDING PERIOD: a. Start Date: | b. End Date: *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 Process for r eview on: b. Program is subject to E.O. 12372 but has not been selected by State for r eview. 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 **T he 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 extensi on) 17b. Signature of Authorized Certifying Official on) | 17d. Email Address: 17e. Date Report Submitted (Month, Day, Year) Attach supporting documents as specified in agency instructions

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN Section 1 – Program Components 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) 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 Cooling assistance Weatherization assistance Summer Crisis assistance Winter Crisis assistance Year - round crisis 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 (auto - po p ulate) Heating assistance Cooling assistance Summer crisis assistance Winter crisis assistance Year - round crisis assistance Weatherization assistance Carryover to the following federal fiscal year Administrative and planning costs Services to reduce home energy needs including needs assessment (Assurance 16) Used to develop and implement leverages activities TOTAL: 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- f ederal sources. 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 p rograms | ☐ Yes | ☐ No | ☐ Yes | ☐ No | ☐ Yes | ☐ No | ☐ Yes | ☐ No 1.4 a. 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? 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: | $ 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 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 or 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 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, emailed, dropped off in-person , or faxed 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 local subgrant recipients have an online application 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: 1.11 Do you have a process for conducting and completing applications by phone: 1.12 Do you or any of your subrecipients require in person appointments in order to apply? 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 Mail Email Portal application Other, describe:

Section 2 - HEATING ASSISTANCE

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- 0075 Expiration Date: 02/28/2027 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 S ize | Eligibility Guideline | Eligibility Threshold 2.2 Do you have additional eligibility requirements for heating assistance? Yes | 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 or differing eligibility policies for: Renters? | Yes | No If yes, describe: Renters l iving in subsidized housing ? | Yes | No If yes, describe: Renters with utilities included in the rent ? | Yes | No If yes, describe: Do you give priority in eligibility to: Older adults? | Yes | No If yes, describe: Individuals with a disability? | Yes | No If yes, describe: Young children? | Yes | No If yes, describe: Households with high energy burdens ? | Yes | No If yes, describe: Other? | Yes | No If yes, describe: 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. 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 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 | Maximum Benefit 2.7 Do you provide in-kind (e.g., blankets, space heaters) or other forms of benefits? Yes | 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.

Section 3 - COOLING ASSISTANCE

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 3 – Cooling Assistance Eligibility, 2605(b)(2) - Assurance 2 3 .1 Designate the income eligibility threshold used for the cooling component: Add | Household size | Eligibility Guideline | Eligibility Threshold 3 .2 Do you have additional eligibility requirements for cooling assistance? Yes | No 3 .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 or differing eligibility policies for: Renters? | Yes | No If yes, describe: Renters l iving in subsidized housing ? | Yes | No If yes, describe: Renters with utilities included in the rent ? | Yes | No If yes, describe: Do you give priority in eligibility to: Older adults? | Yes | No If yes, describe: Individuals with a disability? | Yes | No If yes, describe: Young children? | Yes | No If yes, describe: Households with high energy burdens ? | Yes | No If yes, describe: Other? | Yes | No If yes, describe: Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B) 3 .4 Describe how you prioritize the provision of cooling assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc. 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 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 | Maximum Benefit 3 .7 Do you provide in-kind (e.g., fans, air conditioners ) and/or other forms of benefits? Yes | 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.

Section 4 - CRISIS ASSISTANCE

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 4 – Crisis Assistance Eligibility, 2605(b)(2) - Assurance 2 4 .1 Designate the income eligibility threshold used for the cooling component: Add | Household size | Eligibility Guideline | Eligibility Threshold 4.2 Provide your LIHEAP program's definition for determining a crisis. If you administer multiple crisis assistance programs (i.e. winter, summer, or year - round), include all program definitions. 4.3 What constitutes a life-threatening crisis? Crisis Requirement, 2604(c) 4.4 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? 48 hours 4.5 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening situations? 18 hours Crisis Eligibility, 2605(c)(1)(A) Winter Crisis | Summer Crisis | Year - Round 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 Do you require an a ssets test ? Do you give priority in eligibility to : Older adults? Individuals with a disability? Young c hildren ? Households with high energy burdens? Other? 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 or cooling be medically necessary? Must the household have non-working heating or cooling equipment? Other? Do you have additional or 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: 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. | $ Other - Describe: 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 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 | Maximum Benefit | $ Summer Crisis | Maximum Benefit | $ Year - Round Crisis | Maximum Benefit | $ 4.13 Do you provide in-kind (e.g. , blankets, space heaters, fans) 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 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? Yes | 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.

Section 5 - WEATHERIZATION ASSISTANCE

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- 0075 Expiration Date: 02/28/2027 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 5.2 Do you enter into an interagency agreement to have another government agency administer a Weatherization component? Yes | No 5.3 If yes, name the agency and attach a copy of the i nternal a greement or c ontract. 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- and 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 t hreshold 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 or differing eligibility policies for : Do you require an a ssets test ? | Yes | No Do you have additional or differing eligibility policies for: Renters? | Yes | No Renters l iving in subsidized housing ? | Yes | No Renters with utilities included in the rent ? | Yes | No Do you give priority in eligibility to: Older adults? | Yes | No Individuals with a disability? | Yes | No Young children? | Yes | No Households with high energy burdens ? | Yes | No 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 or expenditure per household? Yes | No If yes, what is the maximum: | $ 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 Compact florescent light bulbs | Community Solar projects Rooftop solar | 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.

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 6 – Outreach 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 low-income programs. Execute interagency agreements with other low-income program offices to perform outreach to target groups. Web posting Email 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.

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 7 – Coordination 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 or from other programs Indicate programs included: 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.

Section 8 - Agency Designation, 2605(b)(6) - Assurance 6

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 8 – Agency Designation 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 s tate agency? Administration Agency Commerce Agency Community Services Agency Energy/Environment Agency Housing Agency State Department of Welfare Agency (administers TANF, SNAP, and/or Medicaid) Economic Development Agency Other - Describe: Alternate Outreach and Intake, 2605(b)(15) - Assurance 15 If you selected "Welfare Agency" 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 W ho 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 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 non - compliance 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? Yes | No 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.

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 9 – Energy Suppliers 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? 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? 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? 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.

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 10 – Program, Fiscal Monitoring, and Audit Section 10: Program, Fiscal Monitoring, and Audit, 2605(b)(10) 10.1. How do you ensure proper fiscal accounting and tracking of funds ? Be specific about tracking of grant award, tracking of expenditures, tracking vendor (benefit) refunds, fiscal reporting process, and fiscal software systems being used. 10.1a Provide Definitions for the following: Obligation: Expenditures: Expenditure timeframe : Administrative 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 a 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 or district offices? Select all that apply. Local agencies and district offices are required to have an annual audit in compliance with Single Audit Act and OMB Circular A-133 . Local agencies and district offices are required to have an annual audit (other than A-133) . Local agencies or 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 or 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 recipient employees: Internal program review Departmental oversight Secondary review of invoices and payments Other program review mechanisms are in place. Describe: Local Administering Agencies or District Offices: On-site evaluation Annual program review Monitoring through central database Desk reviews Client F ile T esting /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. Annually Biannually Triannually Other, 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.

Section 11 - Timely and Meaningful Public Participation, 2605(b)(12) - Assurance 12, 2605(c)(2)

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 11 – Timely and Meaningful Public Participation Section 11: Timely and Meaningful Public Participation, 2605(b)(12), 2605(C)(2) 11.1 How did you obtain input from the public in the development of your LIHEAP plan? Select all that apply. Note: T ribes do not need to hold a public hearing but must ensure participation through other means. Tribal Council meeting(s) Public Hearing(s) Draft Plan posted to website and available for comment . Hard copy of plan is available for public view and comment . Comments from applicants are recorded . Request for comments on draft Plan is advertised . Stakeholder consultation meeting(s) Comments are solicited during outreach activities . Other - Describe: Public Hearings, 2605(a)(2) - For States and the Commonwealth of Puerto Rico Only 11.3 List the date and location(s) that you held public hearing(s) on the proposed use and distribution of your LIHEAP funds? Date | Event Description 1 2 11.4. How many parties commented on your plan at the hearing(s)? 11.5 Summarize the comments you received at the hearing(s). 11.6 What changes did you make to your LIHEAP plan as a result of public participation and solicitation of input ? 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.

Section 12 - Fair Hearings, 2605(b)(13) - Assurance 13

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 12 – Fair Hearings Section 12: Fair Hearings, 2605(b)(13) - Assurance 13 12.1 How many fair hearings did the grant recipient have in the prior f ederal F iscal Y ear? 12.2 How many of those fair hearings resulted in the initial decision being reversed? 12.3 Describe any policy or procedural changes made in the last f ederal F iscal Y ear as a result of fair hearings? 12.4 Describe your fair hearing procedures for households whose applications are denied or not acted upon in a timely manner . 12.5 When and how are applicants informed of these rights? 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.

Section 13 - Reduction of home energy needs, 2605(b)(16) - Assurance 16

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 13 – Reduction of Home Energy Needs Section 13: Reduction of H ome E nergy N eeds, 2605(b)(16) - Assurance 16 13.1 Describe how you use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and thereby the need for energy assistance? 13.2 How do you ensure that you don't use more than 5% of your LIHEAP funds for these activities? 13.3 Describe the impact of such activities on the number of households served in the previous f ederal F iscal Y ear? Impact can be measured in many different ways: using logic models, data tracking systems, process evaluation, impact evaluation, number of households served versus applied, and performance management for example . 13.4 Describe the level of direct benefits provided to those households in the previous f ederal F iscal Y ear. 13.5 How many households received these services? 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.

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 14 – Leveraging Incentive Program 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 or local agencies for submitting LIHEAP leveraging resource information and retaining records. 14.3 For each type of resource 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 benefit? | What is the source(s) of the resource? | How will the resource be integrated and coordinated with LIHEAP? 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.

Section 15 - Training

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP) MODEL PLAN Section 1 5 – Training Section 15: Training 15.1 Describe the training you provide for each of the following groups: a. Grant recipient S taff: Formal training provided virtually, on-site, and/or formal training conference How often? Annually Biannually As needed Other - Describe: Employees are provided with policy manual Other - Describe: b. Local Agencies: Formal training provided virtually, on-site, and/or formal training conference How often? Annually Biannually As needed Other - Describe: Employees are provided with policy manual Other - Describe: c. Vendors Formal training provided virtually, on-site, and/or formal training conference How often? Annually Biannually As needed Other - Describe: Policies communicated through vendor agreements Policies are outlined in a vendor manual 15. 2 Does your training program address fraud reporting and prevention? Yes | No

Section 16 - Performance Goals and Measures, 2605(b)

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 16 – Performance Goals and Measures Section 16: Performance Goals and Measures, 2605(b) - Required for States Only 16.1 Describe your progress toward meeting the data collection and reporting requirements of the four required LIHEAP performance measures. Include timeframes and plans for meeting these requirements and what you believe will be accomplished in the coming federal F iscal Y ear. 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.

Section 17 - Program Integrity, 2605(b)(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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 17 – Program Integrity Section 17: Program Integrity, 2605(b)(10) 17.1 Fraud Reporting Mechanisms a. Describe all mechanisms available to the public for reporting cases of suspected waste, fraud, and abuse. Select all that apply. Online Fraud Reporting Dedicated Fraud Reporting Hotline Report directly to local agency/district office or Grant recipient office Report to State Inspector General or Attorney General Forms and procedures in place for local agencies/district offices and vendors to report fraud, waste, and abuse Posted in local admin i stering agencies offices Other - Describe: b. Describe strategies in place for advertising the above referenced resources. Select all that apply Printed outreach materials Addressed on LIHEAP application Website Printed outreach materials Other - Describe: 17.2. Identification Documentation Requirements a. Indicate which of the following forms of identification are required or requested to be collected from LIHEAP applicants or their household members. Type of Identification Collected | Collected from Whom? Applicant Only | All Adults in Household | All Household Members Social Security c ard is photocopied and retained | Required | Required | Required Requested | Requested | Requested Social Security n umber (Without actual Card) | Required | Required | Required Requested | Requested | Requested Government-issued identification card (i.e. , driver's license, state ID, Tribal ID, passport, etc.) | Required | Required | Required Requested | Requested | Requested Other | Applicant Only Required | Applicant Only Requested | All Adults in Household Required | All Adults in Household Requested | All Household Members Required | All Household Members Requested 1 b. Describe any exceptions to the above policies. 17.3 Identification Verification Describe what methods are used to verify the authenticity of identification documents provided by clients or household members. Select all that apply Describe what methods are used to verify the authenticity of identification documents provided by clients or household members. Select all that apply Verify SSNs with Social Security Administration Match SSNs with death records from Social Security Administration or state agency Match SSNs with state eligibility/case management system (e.g., SNAP, TANF) Match with state Department of Labor system Match with state and/or federal corrections system Match with state child support system Verification using private software (e.g., The Work Number) In-person certification by staff (for tribal grant recipients only) Match SSN/Tribal ID number with tribal database or enrollment records (for tribal grant recipients only) Other - Describe: 17.4. Citizenship or Legal Residency Verification What are your procedures for ensuring that household members are U.S. citizens or qualified non-citizens who are qualified to receive LIHEAP benefits? Select all that apply. Clients sign an attestation of citizenship or U.S. c itizen or q ualified non-citizen. Client's submission of Social Security cards is accepted as proof of U.S. c itizen or q ualified n on- c itizen. Non - citizens must provide documentation of immigration status . Citizens must provide a copy of their birth certificate, naturalization papers, or passport . Non - citizens are verified through the SAVE system . Tribal members are verified through Tribal enrollment records/Tribal ID card . Other - Describe: 17.5. Income Verification What methods does your agency utilize to verify household income? Select all that apply. Require documentation of income for all adult household members Pay stubs Social Security award letters Bank statements Tax statements Zero income statements Unemployment Insurance letters Other - Describe: Computer data matches: Income information matched against state computer system (e.g., SNAP, TANF) Proof of unemployment benefits verified with state Department of Labor Social Security income verified with SSA Utilize state directory of new hires Other - Describe: 17.6. Protection of Privacy and Confidentiality Describe the financial and operating controls in place to protect client information against improper use or disclosure. Select all that apply. Policy in place prohibiting release of information without written consent Grant recipient LIHEAP database includes privacy/confidentiality safeguards . Employee training on confidentiality for: Grant recipient employees Local agencies/district offices Employees must sign confidentiality agreement Grant recipient employees Local agencies/district offices Physical files are stored in a secure location . Electronic files are protected in a secure location . Other - Describe: 17.7. Verifying the Authenticity What policies are in place for verifying vendor authenticity? Select all that apply. All vendors must register with the s tate/ t ribe. All vendors must supply a valid SSN or TIN/W-9 form . Vendors are verified through energy bills provided by the household . Grant recipient and/or local agencies/district offices perform physical monitoring of vendors . Other - Describe and note any exceptions to policies above: 17.8. Benefits Policy - Gas and Electric Utilities What policies are in place to protect against fraud when making benefit payments to gas and electric utilities on behalf of clients? Select all that apply. Applicants required to submit proof of physical residency . Applicants must submit current utility bill . Data exchange with utilities that verifies: Account ownership Consumption Balances Payment history Account is properly credited with benefit Other - Describe: Centralized computer system/database tracks payments to all utilities . Centralized computer system automatically generates benefit level . Separation of duties between intake and payment approval . Payments coordinated among other energy assistance programs to avoid duplication of payments . Payments to utilities and invoices from utilities are reviewed for accuracy . Computer databases are periodically reviewed to verify accuracy and timeliness of payments made to utilities . Direct payment to households are made in limited cases only . Procedures are in place to require prompt refunds from utilities in cases of account closure . Vendor agreements specify requirements selected above and provide enforcement mechanism . Other - Describe: 17.9. Benefits Policy - Bulk Fuel Vendors What procedures are in place for averting fraud and improper payments when dealing with bulk fuel suppliers of heating oil, propane, wood, and other bulk fuel vendors? Select all that apply. Vendors are checked against an approved vendor list . Centralized computer system/database is used to track payments to all vendors . Clients are relied on for reports of non-delivery or partial delivery . Two-party checks are issued naming client and vendor . Direct payment to households is made in limited cases only . Vendors are only paid once they provide a delivery receipt signed by the client . Conduct monitoring of bulk fuel vendors . Bulk fuel vendors are required to submit reports to the g rant recipient . Vendor agreements specify requirements selected above, and provide enforcement mechanism Other - Describe: 17.10. Investigations and Prosecutions Describe the Grant recipient's procedures for investigating and prosecuting reports of fraud, and any sanctions placed on clients , staff , or vendors found to have committed fraud. Select all that apply. Refer to state Inspector General . Refer to local prosecutor or state Attorney General . Refer to U . S . DHHS Inspector General (including referral to OIG hotline ) . Local agencies/district offices or Grant recipient conduct investigation of fraud complaints from public . Grant recipient attempts collection of improper payments. If so, describe the recoupment process . Clients found to have committed fraud are banned from LIHEAP assistance. For how long is a household banned? Contracts with local agencies require that employees found to have committed fraud are reprimanded and/or terminated . Vendors found to have committed fraud may no longer participate in LIHEAP . 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.

Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 18 – Certification Regarding Debarment, Suspension, and Other Responsibility Matters Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions Instructions for Certification By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction. The prospective primary participant further agrees by submitting this proposal that it will include the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transaction,'' provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals: Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions Instructions for Certification By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled ``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,'' without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. Certification Regarding Debarment, Suspension, Ineligibility a Voluntary Exclusion--Lower Tier Covered Transactions (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal By checking this box, the prospective primary participant is providing the certification set out above.

Section 19: Certification Regarding Drug-Free Workplace Requirements

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 19 – Certification Regarding Drug-Free Workplace Requirements Section 19: Certification Regarding Drug-Free Workplace Requirements This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATEWIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central p o int is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201. Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification) By signing and/or submitting this application or grant agreement, the grant recipient is providing the certification set out below. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grant recipient knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act. For grant recipients other than individuals, Alternate I applies. For grant recipients who are individuals, Alternate II applies. Workplaces under grants, for grant recipients other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If the grant recipient does not identify the workplaces at the time of application, or upon award, if there is no application, the grant recipient must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grant recipient's drug-free workplace requirements. Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios). If the workplace identified to the agency changes during the performance of the grant, the grant recipient shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five). Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grant recipients' attention is called, in particular, to the following definitions from these rules: Controlled substance means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15); Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes; Criminal drug statute means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance; Employee means the employee of a grant recipient directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grant recipient's payroll. This definition does not include workers not on the payroll of the grant recipient (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grant recipient's payroll; or employees of subrecipients or subcontractors in covered workplaces). Certification Regarding Drug-Free Workplace Requirements Alternate I. (Grant recipients Other Than Individuals) The grant recipient certifies that it will or will continue to provide a drug-free workplace by:, Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grant recipient's workplace and specifying the actions that will be taken against employees for violation of such prohibition; Establishing an ongoing drug-free awareness program to inform employees about -- The dangers of drug abuse in the workplace; The grant recipient's policy of maintaining a drug-free workplace; Any available drug counseling, rehabilitation, and employee assistance programs; and The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will -- Abide by the terms of the statement; and Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; (e) Notifying the agency in writing, within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant; (f)Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d)(2), with respect to any employee who is so convicted -(1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). (B) The grant recipient may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: Place of Performance (Street address, city, county, state, zip code) * Address Line 1, do not enter P.O. Box Address Line 2 Address Line 3 *City | *State | *Zip Code Check if there are workplaces on file that are not identified here. Alternate II. (Grant recipients Who Are Individuals) The grant recipient certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant; If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant. [55 FR 21690, 21702, May 25, 1990] By checking this box, the prospective primary participant is providing the certification set out above.

Section 20: Certification Regarding Lobbying

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 20 – Certification Regarding Lobbying Section 20: Certification Regarding Lobbying The submitter of this application certifies, to the best of his or her knowledge and belief, that: No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, `` ” “Disclosure Form to Report Lobbying,’’ in accordance with its instructions The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Statement for Loan Guarantees and Loan Insurance The undersigned states, to the best of his or her knowledge and belief, that: If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,’’ in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. By checking this box, the prospective primary participant is providing the certification set out above.

Section 21: Assurances

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Assurances use the funds available under this title to— conduct outreach activities and provide assistance to low - income households in meeting their home energy costs, particularly those with the lowest incomes that pay a high proportion of household income for home energy, consistent with paragraph (5); intervene in energy crisis situations; provide low-cost residential weatherization and other cost-effective energy-related home repair; and plan, develop, and administer the State's program under this title including leveraging programs, and the State agrees not to use such funds for any purposes other than those specified in this title; make payments under this title only with respect to- - households in which one or more individuals are receiving-- (i)assistance under the State program funded under part A of title IV of the Social Security Act; supplemental security income payments under title XVI of the Social Security Act; food stamps under the Food Stamp Act of 1977; or payments under section 415, 521, 541, or 542 of title 38, United States Code, or under section 306 of the Veterans' and Survivors' Pension Improvement Act of 1978; or households with incomes which do not exceed the greater of - an amount equal to 150 percent of the poverty level for such State; or an amount equal to 60 percent of the State median income; (except that a State may not exclude a household from eligibility in a fiscal year solely on the basis of household income if such income is less than 110 percent of the poverty level for such State, but the State may give priority to those households with the highest home energy costs or needs in relation to household income. conduct outreach activities designed to assure that eligible households, especially households with elderly individuals or disabled individuals, or both, and households with high home energy burdens, are made aware of the assistance available under this title, and any similar energy-related assistance available under subtitle B of title VI (relating to community services block grant program) or under any other provision of law which carries out programs which were administered under the Economic Opportunity Act of 1964 before the date of the enactment of this Act; coordinate its activities under this title with similar and related programs administered by the Federal Government and such State, particularly low-income energy-related programs under subtitle B of title VI (relating to community services block grant program), under the supplemental security income program, under part A of title IV of the Social Security Act, under title XX of the Social Security Act, under the low-income weatherization assistance program under title IV of the Energy Conservation and Production Act, or under any other provision of law which carries out programs which were administered under the Economic Opportunity Act of 1964 before the date of the enactment of this Act; provide, in a timely manner, that the highest level of assistance will be furnished to those households which have the lowest incomes and the highest energy costs or needs in relation to income, taking into account family size, except that the State may not differentiate in implementing this section between the households described in clauses 2(A) and 2(B) of this subsection; to the extent it is necessary to designate local administrative agencies in order to carry out the purposes of this title, to give special consideration, in the designation of such agencies, to any local public or private nonprofit agency which was receiving Federal funds under any low-income energy assistance program or weatherization program under the Economic Opportunity Act of 1964 or any other provision of law on the day before the date of the enactment of this Act, except that - the State shall, before giving such special consideration, determine that the agency involved meets program and fiscal requirements established by the State; and if there is no such agency because of any change in the assistance furnished to programs for economically disadvantaged persons, then the State shall give special consideration in the designation of local administrative agencies to any successor agency which is operated in substantially the same manner as the predecessor agency which did receive funds for the fiscal year preceding the fiscal year for which the determination is made; if the State chooses to pay home energy suppliers directly, establish procedures to -- notify each participating household of the amount of assistance paid on its behalf; 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 made by the State under this title; assure that the home energy supplier will provide assurances that any agreement entered into with a home energy supplier under this paragraph will contain provisions to assure that no household receiving assistance under this title will be treated adversely because of such assistance under applicable provisions of State law or public regulatory requirements; and ensure that the provision of vendor payments remains at the option of the State in consultation with local grant recipients and may be contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible households, including providing for agreements between suppliers and individuals eligible for benefits under this Act that seek to reduce home energy costs, minimize the risks of home energy crisis, and encourage regular payments by individuals receiving financial assistance for home energy costs; provide assurances that, the State will not exclude households described in clause (2)(B) of this subsection from receiving home energy assistance benefits under clause (2), and the State will treat owners and renters equitably under the program assisted under this title; provide that- - the State may use for planning and administering the use of funds under this title an amount not to exceed 10 percent of the funds payable to such State under this title for a fiscal year; and the State will pay from non-Federal sources the remaining costs of planning and administering the program assisted under this title and will not use Federal funds for such remaining cost (except for the costs of the activities described in paragraph (16)); provide that such fiscal control and fund accounting procedures will be established as may be necessary to assure the proper disbursal of and accounting for Federal funds paid to the State under this title, including procedures for monitoring the assistance provided under this title, and provide that the State will comply with the provisions of chapter 75 of title 31, United States Code (commonly known as the "Single Audit Act"); permit and cooperate with Federal investigations undertaken in accordance with section 2608; provide for timely and meaningful public participation in the development of the plan described in subsection (c); provide an opportunity for a fair administrative hearing to individuals whose claims for assistance under the plan described in subsection (c) are denied or are not acted upon with reasonable promptness; and cooperate with the Secretary with respect to data collecting and reporting under section 2610. * beginning in fiscal year 1992, provide, in addition to such services as may be offered by State Departments of Public Welfare at the local level, outreach and intake functions for crisis situations and heating and cooling assistance that is administered by additional State and local governmental entities or community-based organizations (such as community action agencies, area agencies on aging and not-for-profit neighborhood-based organizations), and in States where such organizations do not administer functions as of September 30, 1991, preference in awarding grants or contracts for intake services shall be provided to those agencies that administer the low-income weatherization or energy crisis intervention programs. * This assurance is applicable only to States, and to territories whose annual regular LIHEAP allotments exceed $200,000. Neither territories with annual allotments of $200,000 or less nor Indian tribes/tribal organizations are subject to Assurance 15. (16) use up to 5 percent of such funds, at its option, to provide services that encourage and enable households to reduce their home energy needs and thereby the need for energy assistance, including needs assessments, counseling, and assistance with energy vendors, and report to the Secretary concerning the impact of such activities on the number of households served, the level of direct benefits provided to those households, and the number of households that remain unserved. By checking this box, the prospective primary participant is providing the certification set out above.

Plan Attachments

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- 0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Plan Attachments The following documents must be attached to this application Delegation Letter is required if someone other than the Governor or Chairman Certified this Report. Heating component benefit matrix, if applicable Cooling component benefit matrix, if applicable Minutes, notes, or transcripts of public hearing(s). Optional: Policy Manual Optional: Subrecipient contract Optional: Model Plan Participation notes for Tribes

AT#: LIHEAP-AT-2025-04

DATE: April 2, 2025

TO : All LIHEAP Grant Recipients

SUBJECT : Model Plan Application for LIHEAP Funding for Federal Fiscal Year 2026 (FY26) (Application deadline Tuesday, September 2, 2025)

ATTACHMENT(S) : 1. How to Use the Clone Report Feature in OLDC to Submit a New FY26 LIHEAP Plan. 2. LIHEAP Model Plan Reference Guide. 3. FY26 Model Plan Form

PURPOSE: To provide Low Income Home Energy Assistance (LIHEAP) grant recipients with instructions for how to apply online for federal Fiscal Year 2026 (FY26) LIHEAP funding, confirm the September 2, 2025 LIHEAP Model Plan submission deadline, and remind grant recipients they can “clone” or pre-populate their prior data into a new Plan submission to reduce administrative reporting burden.

BACKGROUND: States, the District of Columbia, territories, and Tribes or Tribal organizations that wish to administer LIHEAP must submit an application for funds by September 1st (or the date issued by the Office of Community Services (OCS)) each FY, covering a grant period of October 1 through September 30. Section 2605(c)(3) of the Low Income Home Energy Assistance Act of 1981, as amended (42 U.S.C. § 8624(c)(3)), provides that the Secretary shall make available a model LIHEAP Plan which may be used to prepare the application required under Sections 2605(a)(1) and (c)(1) (42 U.S.C. § 8624(a)(1) and (c)(1)).

OCS has the responsibility to review and accept LIHEAP Model Plan submissions on behalf of the U.S. Department of Health and Human Services’ (HHS’) Administration for Children and Families (ACF). The Office of Management and Budget (OMB) approved ACF’s LIHEAP Model Plan form under clearance number 0970-0075 effective through February 28, 2027.

The deadline for the FY26 Plan is Tuesday, September 2, 2025 .

Grant recipients must submit the LIHEAP Model Plan via the Online Data Collection (OLDC), located within GrantSolutions , each FY in order to receive LIHEAP funding allocation.

In FY26, LIHEAP grant recipients can “clone” or pre-populate their FY25 data into a new Plan, but they must follow the application process outlined below.

All grant recipients must complete the entire LIHEAP Model Plan for FY26 in OLDC. Grant recipients can transfer information from the FY25 LIHEAP Plan (prior plan) into the new Plan by using the “Clone Report” feature in OLDC. Attachment 1 provides step-by-step instructions for how to use the “Clone Report” feature.

After transferring prior year information into the new Plan, at a minimum, grant recipients must update responses to the following sections:

SF-424 Mandatory Grant Application section — Fields 1.d., 7.d. (this section will be used as the official point of contact for federal LIHEAP website), 13.a., 13b. Funding Period, and fields 16 and 17 Authorized Official through the Letter of Delegation;

Section 1-Program Components, 2605(b)(1)-Question 1.1 Dates of Operations and Question 1.2 Estimated Funding Allocations;

Section 2—Heating Assistance, 2605(b)(2) — Question 2.1 Eligibility Threshold; Section 3—Cooling Assistance, 2605(b)(2) — Question 3.1 Eligibility Threshold; Section 4 — Crisis Assistance, 2605(c) — Question 4.1 Eligibility Threshold;

Section 5—Weatherization Assistance, 2605(b)(2) — Question 5.1 Eligibility Threshold;

Section 8 — Agency Designation, 2605(b)(6)-Assurance 6 — Question 8.8. This section is required for state grant recipients and the Commonwealth of Puerto Rico only;

Section 10 — Program, Fiscal Monitoring, and Audit, 2605(b)(10)-Assurance 10 — Questions

10.3 and 10.9;

Section 11 — Timely and Meaningful Public Participation, 2605(b)(12), 2605(c)(2) — Questions 11.1-11.5;

Section 12 — Fair Hearings, 2605(b)(10) — Questions 12.1-12.3;

Section 13 — Reduction of home energy needs, 2605(b)(16) — Questions 13.1-13.5; and

Section 16 — Performance Goals and Measures, 2605(b). This section is required of state grant recipients only and optional for other grant recipients.

Attach supporting documentation or provide links to supporting documents online, as needed, such as policies and procedures.

A note on leveraging activities: The LIHEAP Model Plan includes an optional section (Section 14) to explain possible leveraging activities the grant recipient may take during FY26. Completing this section is one requirement to receive a separate leveraging grant, if funding is available.

However, OCS awards leveraging grants in the federal FY following the year the grant recipient conducted the leveraging activities. Therefore, if funding is available, OCS would award leveraging grants in FY26 based upon a separate leveraging report that would be reconciled against the responses in the FY25 LIHEAP Model Plan for leveraging activities that took place in FY25. OCS last awarded leveraging grants in FY12 and has no estimate for when federal leveraging grants will become available again. However, grant recipients are encouraged to complete this section if they had leveraged non-federal funds to assist LIHEAP bill payment or weatherization assistance households so that the public and all interested parties can review and comment on the grant recipient’s efforts.

The Assurances displayed in the Section 21 of the LIHEAP Model Plan are from the federal LIHEAP statute (42 U.S.C. § 8624(b)(1)-(16)). LIHEAP regulations at 45 C.F.R. § 96.10(b) require that the 16 Assurances (15 for Tribes) in the LIHEAP statute be certified by the grant recipient’s Chief Executive Officer or “by an individual authorized to make such certifications on behalf of the Chief Executive Officer.” For the LIHEAP Model Plan to be approved, please be sure that the governor or Tribal chairperson (1) certifies the Assurances or (2) has specifically delegated authority to “certify” the LIHEAP Assurances to another person or position (not merely the department or agency). The grant recipient must attach a delegation letter to the LIHEAP Model Plan in OLDC, and the letter must explicitly specify that the individual is authorized to certify the federal LIHEAP Assurances.

In addition to the LIHEAP Model Plan, grant recipients must also complete or update the Mandatory Grant Application SF-424, which is the first section of the LIHEAP Model Plan in OLDC. The person that is designated to “certify to the LIHEAP Assurances” must have an OLDC account and, while logged into their OLDC account, must be the person that clicks the “Certify” and “Click to Sign” buttons for the LIHEAP Model Plan in OLDC. Therefore, if the governor or Tribal chairperson chooses not to designate someone else to sign the LIHEAP Assurances, then the governor or Tribal chairperson must have their own account and “certify” the FY26 LIHEAP Model Plan in OLDC.

States, the District of Columbia, and territories receiving more than $200,000 must describe in their new FY26 Plan how they will carry out Assurance 15 (Section 2605(b)(15) of the LIHEAP statute (42 U.S.C. § 8624(b)(15)). Assurance 15 requires such grant recipients to offer LIHEAP intake services in addition to those available through agencies also administering the Temporary Assistance for Needy Families (TANF) program. An attachment detailing this plan may be added or entered in any of the fields in Sections 8.2, 8.3, and 8.4.

Section 18 — All LIHEAP grant recipients must agree to the Certification Regarding Debarment, Suspension, and Other Responsibility Matters.

Section 19 — All LIHEAP grant recipients must submit the Certification Regarding Drug-Free Workplace Requirements unless a state has submitted a statewide Assurance to the S. Department of Health and Human Services. When completing this certification, be sure to enter the grant recipient’s physical address in the appropriate fields. No post office (P.O.) boxes allowed.

Section 20 — States, the District of Columbia, territories, and Tribes must file the Certification Regarding Lobbying and, if applicable, Form LLL, which discloses lobbying payments.

Section 21- All LIHEAP grant recipients must agree to the Assurances set

The LIHEAP Plan form in OLDC, Sections 18-21, incorporates all the above certifications. Please ensure that the certification checkbox is marked in each required certification’s section.

States and Territories: Section 2605 (a)(2) of the federal LIHEAP statute requires states and territories to conduct public hearings on the proposed use and distribution of funds as outlined in the FY26 LIHEAP Plan (42 U.S.C. §8624(a)(2)). Grant recipients should follow their own state and territorial procedures for public

Tribes: No hearing is required of Tribal grant recipients. However, Tribal grant recipients are required to obtain timely and meaningful public participation or input from their communities regarding their draft or proposed FY26 LIHEAP This may include some combination of web postings, public service announcements, comments by email or phone, stakeholder calls, etc. Tribes must follow their Tribal-wide rules for public participation that they would use with Tribal funding. Note: Timely means that the public participation process must be completed in advance of and prior to the submission of the Plan to get public comments and allow enough time for internal review.

The following documents must be attached to the application in OLDC to be considered complete.

Delegation Letter (required if someone other than the Chief Executive, g., a governor or Tribal chairperson certified the FY Plan in OLDC).

Benefit matrices showing at least three varying measures (income, household size, and energy costs or needs) to determine benefit types, such as heating, cooling, and crisis assistance. Use the applicable new income guidelines published here .

Minutes, notes, or transcripts of public hearing(s) (states and territories only) or public participation (Tribes).

Optional: Policy Manual, Subrecipient Contract, Model Plan Participation Notes for Tribes.

OCS encourages directly funded Tribes that receive smaller annual LIHEAP grants to consider joining an existing consortium in their state(s) or forming a consortium with neighboring Tribes to reduce the administrative burden of the LIHEAP Plan submission and the required reports. For information on how to form or join a consortium, inquire with your federal LIHEAP regional liaison . This information is available under Section B of the LIHEAP Grantee Resource

Guide (formerly known as the Tribal Manual).

Submission Deadline Extension : If a grant recipient anticipates needing an extension of the September 2, 2025 Plan submission deadline, the grant recipient must submit a letter requesting a deadline extension. The letter must be uploaded as an attachment to an

“initialized” FY26 Plan and provide a specific, reasonable alternative date and a brief explanation of the reason for needing an extension. Tribal grant recipients must obtain written agreement of the extension date from the states in which the Tribe’s service areas are located. The state’s email or letter of concurrence must also be included as an attachment to the initialized 2026 Plan. Extension requests must be submitted to OCS prior to Tuesday, September 2, 2025.

Follow-up Action on Plan Submissions : Upon receipt of FY26 Plans, OCS staff will review the Plans and either reject the Plan back to the grant recipient via OLDC or accept the plan in OLDC. Grant recipients whose plans are “accepted” in OLDC have no further action to take on the Plan. Grant recipients whose plans are “rejected” in OLDC must take immediate action to edit their Plans according to the comments in the OLDC review sections of the Plan and resubmit the edited Plan to OCS within the deadline indicated in the Plan review remarks in OLDC. The federal LIHEAP regulations require that this editing process must be completed no later than December 15, 2025 (45 C.F.R. § 96.10(d)). This deadline is only regarding edits and attachments

that are necessary to resolve missing or inadequate information in the original Plan submission.

OCS will only issue FY26 LIHEAP funding upon receipt and acceptance of a LIHEAP Plan submission that meets statutorily required information. All LIHEAP grant recipients have an ongoing responsibility throughout the grant period to submit revised Plans and reports, as needed, to reflect changes to ensure ACF has final, actual program data.

INQUIRIES: For questions regarding this Model Plan guidance, please contact: Katie Green

Chief of Staff

Office of Community Services Email: kathryn.green@acf.hhs.gov

RELATED REFERENCES: The Low Income Home Energy Assistance Act of 1981, as amended (42 U.S.C. § 8621 et seq .), Block Grant Regulations at 45 C.F.R. Part 96, and LIHEAP IM 2025-02 Federal Poverty Guidelines and State Median Income Estimates for Optional Use in FY25 and Mandatory Use in FY26 .

Please contact Katie Green immediately if you need an OLDC account or have questions about the FY26 Model Plan submission process.

Thank you for your attention to these matters. OCS looks forward to continuing to provide high- quality services to OCS partners.

/s/

Janelle George Acting Director

Division of Energy Assistance Office of Community Services

DOCX COMM_LIHEAP_Model Plan Template draft_032025 (368.84 KB)

PDF COMM_LIHEAP_Model Plan AT_FY26_040225 (273.68 KB)

DOCX COMM_LIHEAP_AT_Att 1_Cloning Instructions_FY2026 (521.52 KB)

PDF COMM_LIHEAP Model Plan Reference Guide_FY26 Final (1,509.90 KB)

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Low Income Home Energy Assistance Program Action Transmittal AT#: LIHEAP-AT-2025-04 DATE: April 2, 2025 TO: All LIHEAP Grant Recipients SUBJECT: Model Plan Application for LIHEAP Funding for Federal Fiscal Year 2026 (FY26) (Application deadline Tuesday, September 2, 2025) ATTACHMENT(S): 1. How to Use the Clone Report Feature in OLDC to Submit a New FY26 LIHEAP Plan. 2. LIHEAP Model Plan Reference Guide. 3. FY26 Model Plan Form

PURPOSE: To provide Low Income Home Energy Assistance (LIHEAP) grant recipients with instructions for how to apply online for federal Fiscal Year 2026 (FY26) LIHEAP funding, confirm the September 2, 2025 LIHEAP Model Plan submission deadline, and remind grant recipients they can “clone” or pre-populate their prior data into a new Plan submission to reduce administrative reporting burden.

BACKGROUND: States, the District of Columbia, territories, and Tribes or Tribal organizations that wish to administer LIHEAP must submit an application for funds by September 1st (or the date issued by the Office of Community Services (OCS)) each FY, covering a grant period of October 1 through September 30. Section 2605(c)(3) of the Low Income Home Energy Assistance Act of 1981, as amended (42 U.S.C. § 8624(c)(3)), provides that the Secretary shall make available a model LIHEAP Plan which may be used to prepare the application required under Sections 2605(a)(1) and (c)(1) (42 U.S.C. § 8624(a)(1) and (c)(1)).

OCS has the responsibility to review and accept LIHEAP Model Plan submissions on behalf of the U.S. Department of Health and Human Services’ (HHS’) Administration for Children and Families (ACF). The Office of Management and Budget (OMB) approved ACF’s LIHEAP Model Plan form under clearance number 0970-0075 effective through February 28, 2027.

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KEY MODEL PLAN SUBMISSION INFORMATION: Plan Submission Deadline: The deadline for the FY26 Plan is Tuesday, September 2, 2025. Grant recipients must submit the LIHEAP Model Plan via the Online Data Collection (OLDC), located within GrantSolutions, each FY in order to receive LIHEAP funding allocation. In FY26, LIHEAP grant recipients can “clone” or pre-populate their FY25 data into a new Plan, but they must follow the application process outlined below. Transferring Prior-Year Information into a New Plan (OLDC “Clone” Feature): All grant recipients must complete the entire LIHEAP Model Plan for FY26 in OLDC. Grant recipients can transfer information from the FY25 LIHEAP Plan (prior plan) into the new Plan by using the “Clone Report” feature in OLDC. Attachment 1 provides step-by-step instructions for how to use the “Clone Report” feature. After transferring prior year information into the new Plan, at a minimum, grant recipients must update responses to the following sections: SF-424 Mandatory Grant Application section — Fields 1.d., 7.d. (this section will be used as the official point of contact for federal LIHEAP website), 13.a., 13b. Funding Period, and fields 16 and 17 Authorized Official through the Letter of Delegation; Section 1-Program Components, 2605(b)(1)-Question 1.1 Dates of Operations and Question 1.2 Estimated Funding Allocations; Section 2—Heating Assistance, 2605(b)(2) — Question 2.1 Eligibility Threshold; Section 3—Cooling Assistance, 2605(b)(2) — Question 3.1 Eligibility Threshold; Section 4 — Crisis Assistance, 2605(c) — Question 4.1 Eligibility Threshold; Section 5—Weatherization Assistance, 2605(b)(2) — Question 5.1 Eligibility Threshold; Section 8 — Agency Designation, 2605(b)(6)-Assurance 6 — Question 8.8. This section is required for state grant recipients and the Commonwealth of Puerto Rico only; Section 10 — Program, Fiscal Monitoring, and Audit, 2605(b)(10)-Assurance 10 — Questions 10.3 and 10.9; Section 11 — Timely and Meaningful Public Participation, 2605(b)(12), 2605(c)(2) — Questions 11.1-11.5;

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Section 12 — Fair Hearings, 2605(b)(10) — Questions 12.1-12.3; Section 13 — Reduction of home energy needs, 2605(b)(16) — Questions 13.1-13.5; and Section 16 — Performance Goals and Measures, 2605(b). This section is required of state grant recipients only and optional for other grant recipients. Attach supporting documentation or provide links to supporting documents online, as needed, such as policies and procedures.

A note on leveraging activities: The LIHEAP Model Plan includes an optional section (Section 14) to explain possible leveraging activities the grant recipient may take during FY26. Completing this section is one requirement to receive a separate leveraging grant, if funding is available. However, OCS awards leveraging grants in the federal FY following the year the grant recipient conducted the leveraging activities. Therefore, if funding is available, OCS would award leveraging grants in FY26 based upon a separate leveraging report that would be reconciled against the responses in the FY25 LIHEAP Model Plan for leveraging activities that took place in FY25. OCS last awarded leveraging grants in FY12 and has no estimate for when federal leveraging grants will become available again. However, grant recipients are encouraged to complete this section if they had leveraged non-federal funds to assist LIHEAP bill payment or weatherization assistance households so that the public and all interested parties can review and comment on the grant recipient’s efforts. Assurances and Certifications: The Assurances displayed in the Section 21 of the LIHEAP Model Plan are from the federal LIHEAP statute (42 U.S.C. § 8624(b)(1)-(16)). LIHEAP regulations at 45 C.F.R. § 96.10(b) require that the 16 Assurances (15 for Tribes) in the LIHEAP statute be certified by the grant recipient’s Chief Executive Officer or “by an individual authorized to make such certifications on behalf of the Chief Executive Officer.” For the LIHEAP Model Plan to be approved, please be sure that the governor or Tribal chairperson (1) certifies the Assurances or (2) has specifically delegated authority to “certify” the LIHEAP Assurances to another person or position (not merely the department or agency). The grant recipient must attach a delegation letter to the LIHEAP Model Plan in OLDC, and the letter must explicitly specify that the individual is authorized to certify the federal LIHEAP Assurances. In addition to the LIHEAP Model Plan, grant recipients must also complete or update the Mandatory Grant Application SF-424, which is the first section of the LIHEAP Model Plan in OLDC. The person that is designated to “certify to the LIHEAP Assurances” must have an OLDC account and, while logged into their OLDC account, must be the person that clicks the “Certify” and “Click to Sign” buttons for the LIHEAP Model Plan in OLDC. Therefore, if the governor or Tribal chairperson chooses not to designate someone else to sign the LIHEAP Assurances, then the governor or Tribal chairperson must have their own account and “certify” the FY26 LIHEAP Model Plan in OLDC.

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States, the District of Columbia, and territories receiving more than $200,000 must describe in their new FY26 Plan how they will carry out Assurance 15 (Section 2605(b)(15) of the LIHEAP statute (42 U.S.C. § 8624(b)(15)). Assurance 15 requires such grant recipients to offer LIHEAP intake services in addition to those available through agencies also administering the Temporary Assistance for Needy Families (TANF) program. An attachment detailing this plan may be added or entered in any of the fields in Sections 8.2, 8.3, and 8.4. Other Certifications: 1. Section 18 — All LIHEAP grant recipients must agree to the Certification Regarding Debarment, Suspension, and Other Responsibility Matters. 2. Section 19 — All LIHEAP grant recipients must submit the Certification Regarding Drug-Free Workplace Requirements unless a state has submitted a statewide Assurance to the U.S. Department of Health and Human Services. When completing this certification, be sure to enter the grant recipient’s physical address in the appropriate fields. No post office (P.O.) boxes allowed. 3. Section 20 — States, the District of Columbia, territories, and Tribes must file the Certification Regarding Lobbying and, if applicable, Form LLL, which discloses lobbying payments. 4. Section 21- All LIHEAP grant recipients must agree to the Assurances set above.

The LIHEAP Plan form in OLDC, Sections 18-21, incorporates all the above certifications. Please ensure that the certification checkbox is marked in each required certification’s section. Meaningful and Timely Public Participation: • States and Territories: Section 2605 (a)(2) of the federal LIHEAP statute requires states and territories to conduct public hearings on the proposed use and distribution of funds as outlined in the FY26 LIHEAP Plan (42 U.S.C. §8624(a)(2)). Grant recipients should follow their own state and territorial procedures for public hearings. • Tribes: No hearing is required of Tribal grant recipients. However, Tribal grant recipients are required to obtain timely and meaningful public participation or input from their communities regarding their draft or proposed FY26 LIHEAP Plan. This may include some combination of web postings, public service announcements, comments by email or phone, stakeholder calls, etc. Tribes must follow their Tribal-wide rules for public participation that they would use with Tribal funding. Note: Timely means that the public participation process must be completed in advance of and prior to the submission of the Plan to get public comments and allow enough time for internal review.

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Required Plan Attachments: The following documents must be attached to the application in OLDC to be considered complete. • Delegation Letter (required if someone other than the Chief Executive, e.g., a governor or Tribal chairperson certified the FY Plan in OLDC). • Benefit matrices showing at least three varying measures (income, household size, and energy costs or needs) to determine benefit types, such as heating, cooling, and crisis assistance. Use the applicable new income guidelines published here. • Minutes, notes, or transcripts of public hearing(s) (states and territories only) or public participation (Tribes). • Optional: Policy Manual, Subrecipient Contract, Model Plan Participation Notes for Tribes.

For Tribal Applicants: OCS encourages directly funded Tribes that receive smaller annual LIHEAP grants to consider joining an existing consortium in their state(s) or forming a consortium with neighboring Tribes to reduce the administrative burden of the LIHEAP Plan submission and the required reports. For information on how to form or join a consortium, inquire with your federal LIHEAP regional liaison. This information is available under Section B of the LIHEAP Grantee Resource Guide (formerly known as the Tribal Manual). Submission Deadline Extension: If a grant recipient anticipates needing an extension of the September 2, 2025 Plan submission deadline, the grant recipient must submit a letter requesting a deadline extension. The letter must be uploaded as an attachment to an “initialized” FY26 Plan and provide a specific, reasonable alternative date and a brief explanation of the reason for needing an extension. Tribal grant recipients must obtain written agreement of the extension date from the states in which the Tribe’s service areas are located. The state’s email or letter of concurrence must also be included as an attachment to the initialized 2026 Plan. Extension requests must be submitted to OCS prior to Tuesday, September 2, 2025. Follow-up Action on Plan Submissions: Upon receipt of FY26 Plans, OCS staff will review the Plans and either reject the Plan back to the grant recipient via OLDC or accept the plan in OLDC. Grant recipients whose plans are “accepted” in OLDC have no further action to take on the Plan. Grant recipients whose plans are “rejected” in OLDC must take immediate action to edit their Plans according to the comments in the OLDC review sections of the Plan and resubmit the edited Plan to OCS within the deadline indicated in the Plan review remarks in OLDC. The federal LIHEAP regulations require that this editing process must be completed no later than December 15, 2025 (45 C.F.R. § 96.10(d)). This deadline is only regarding edits and attachments

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that are necessary to resolve missing or inadequate information in the original Plan submission. OCS will only issue FY26 LIHEAP funding upon receipt and acceptance of a LIHEAP Plan submission that meets statutorily required information. All LIHEAP grant recipients have an ongoing responsibility throughout the grant period to submit revised Plans and reports, as needed, to reflect changes to ensure ACF has final, actual program data. INQUIRIES: For questions regarding this Model Plan guidance, please contact: Katie Green Chief of Staff Office of Community Services Email: kathryn.green@acf.hhs.gov

RELATED REFERENCES: The Low Income Home Energy Assistance Act of 1981, as amended (42 U.S.C. § 8621 et seq.), Block Grant Regulations at 45 C.F.R. Part 96, and LIHEAP IM 2025-02 Federal Poverty Guidelines and State Median Income Estimates for Optional Use in FY25 and Mandatory Use in FY26. Please contact Katie Green immediately if you need an OLDC account or have questions about the FY26 Model Plan submission process. Thank you for your attention to these matters. OCS looks forward to continuing to provide high- quality services to OCS partners.

/s/ Janelle George Acting Director Division of Energy Assistance Office of Community Services

Office of Community Services, Division of Energy Assistance Attachment 1: FY2027 LIHEAP Model Plan Action Transmittal Online Data Collection (OLDC) System Instructions for Low Income Home Energy Assistance Program (LIHEAP) Model Plan Submission How to Use the Clone Report Feature in OLDC to Submit a New FY27 LIHEAP Model Plan The Clone Report feature in OLDC allows the user to populate the fields of a current year’s form with the data from a prior year’s form. Follow the steps below to copy all information from your FY26 Model Plan into your FY27 Model Plan. Step 1: Log into GrantSolutions, then select OLDC at the top right side of the screen. Click on the Report Form Entry link at the top left of the screen. Step 2: This will take you to the Program and Grantee Selection screen. A. In the Program Name dropdown box, select Low Income Home Energy Assistance. B. In the Grantee Name dropdown box, select the grantee name. C. In the Report Name dropdown box, select Model Plan (ACF-122).

Step 3: Click on the button located under Actions. The reporting period is 10/1/2026 – 9/30/2027. This is the FY27 LIHEAP Model Plan reporting period. Step 4: Once you’ve clicked the button it will take you to the Clone Report screen.

A. Select the radio button next to 10/1/2025 - 9/30/2026. This is your FY26 Model Plan and it is the information that you want to copy to your FY27 Model Plan. NOTE: The FY26 Model Plan must be in report status “Submission Accepted by CO” to clone it to FY27. If your report is not in accepted status, reach out to LIHEAP@ACF.HHS.GOV B. Click the “Clone” button.

Step 5: If you’ve followed the above steps properly, you will see a popup message indicating that your report has been cloned successfully. Click the OK button and your FY27 Model Plan will come up with all the information from the FY26 Model Plan prepopulated. Step 6: Go through every section and enter and update the information to reflect the program for FY27. Pay special attention to dates and figures. Step 7: Add any required attachments, such as the updated benefit matrix reflecting the 2026 Federal Poverty Guidelines (FPG) or State Median Income (SMI) Estimates mandatory for use in FY27. Step 8: After all desired sections have been revised and saved, select the Validate option at the top of the report. Fix any errors that are flagged and continue to select Validate until there are no errors. Step 9: Select the Report Sections dropdown menu listed at the top left of the screen. Select Mandatory Grant Application SF-424. Scroll to the bottom of the SF-424 and select Click to Sign. This action certifies the plan. Select the Report Form Status option at the top left of the screen. Step 10: Click Submit. This is the final act of submission of your LIHEAP Plan to OCS.

Low Income Home Energy Assistance Program (LIHEAP) LIHEAP Model Plan Reference Guide

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Table of Contents Introduction to the LIHEAP Model Plan ........................................................................................................ 4 General Information (Mandatory Grant Application – SF-425) .................................................................... 6 Section 1: Program Components .............................................................................................................. 8 Types of Assistance ............................................................................................................................... 8 Funding Allocation ................................................................................................................................ 8 Categorical Eligibility ............................................................................................................................. 9 SNAP Nominal Payments .................................................................................................................... 10 Determination of Eligibility ................................................................................................................. 11 Application Process ............................................................................................................................. 11 Section 2: Heating Assistance ................................................................................................................. 12 Section 3: Cooling Assistance .................................................................................................................. 14 Section 4: Crisis Assistance ..................................................................................................................... 15 Section 5: Weatherization Assistance ..................................................................................................... 17 Section 6: Outreach ................................................................................................................................ 18 Section 7: Coordination .......................................................................................................................... 19 Section 8: Agency Designation ................................................................................................................ 20 Section 9: Energy Suppliers ..................................................................................................................... 21 Section 10: Program, Fiscal Monitoring, and Audit ................................................................................ 22 Section 11: Timely and Meaningful Public Participation ........................................................................ 24 Section 12: Fair Hearings ........................................................................................................................ 25 Section 13: Reduction of Home Energy Needs ....................................................................................... 26 Section 14: Leveraging Incentive Program.............................................................................................. 27 Section 15: Training ................................................................................................................................ 28 Section 16: Performance Goals and Measures ....................................................................................... 29 Section 17: Program Integrity ................................................................................................................. 30 Fraud Reporting Mechanisms ............................................................................................................. 30 Identification Documentation Requirements ..................................................................................... 30 Protection of Privacy and Confidentiality ........................................................................................... 30 Section 18: Certification Regarding Debarment, Suspension, and other Responsibility Matters .......... 31 Section 19: Certification Regarding Drug-free Workplace Requirements .............................................. 32 Section 20: Certification Regarding Lobbying ......................................................................................... 33 Section 21: Assurances ........................................................................................................................... 34

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Plan Attachments .................................................................................................................................... 35 GrantSolutions and OLDC ....................................................................................................................... 36 Access the LIHEAP Model Plan Form ...................................................................................................... 36 Navigating the LIHEAP Model Plan ......................................................................................................... 37 Cloning a Report ...................................................................................................................................... 39 References .................................................................................................................................................. 41

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Introduction to the LIHEAP Model Plan

Your annual Model Plan addresses each part of the Low Income Home Energy Assistance Program (LIHEAP) lifecycle (see Figure 1).

Figure 1: LIHEAP Lifecycle

Grant recipients use their LIHEAP Model Plans to:

• Submit the funding application required under Sections 2605(a)(1) and (c)(1) of the LIHEAP statute • Provide assurances to the U.S. Department of Health and Human Services (HHS) that they will administer the LIHEAP grant in accordance with federal LIHEAP statutes, rules, and regulations • Outline the LIHEAP components for consistent, accurate, and timely provision to household applicants • Set clear guidelines to which recipients and LIHEAP staff can be held accountable • Ensure that recipients are being treated fairly • Train new staff easily and efficiently • Assist during staff and management transitions • Comply with HHS program integrity and other fiscal requirements

Unless a different due date is announced, to receive LIHEAP funds, your LIHEAP Model Plan must be submitted in the Online Data collection (OLDC) system by September 1.

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Your LIHEAP Model Plan may have up to 21 sections. These sections address the various aspects of program and fiscal administration requirements in the LIHEAP statute, including monitoring, training, and other activities.

Keep the following points in mind when developing your LIHEAP Model Plan:

• Only include information in sections that are applicable to your LIHEAP program. • Some sections are only required for state grant recipients. These sections are marked in the section’s title. • Within each section, there are several questions that should be answered. Most questions are required. Those questions that are not required are noted as optional.

➢ Your Model Plan must be an up-to-date reflection of how your LIHEAP program operates.

➢ Your Model Plan must be consistent with your policy manual.

➢ You should not include facets of the program that you do not plan to administer.

➢ If you need to modify your LIHEAP Model Plan at any point in the federal Fiscal Year (FY), you can submit a revision in OLDC.

This reference guide highlights some of the most relevant questions to address within each of these sections, as well as additional items to think about when creating your Model Plan. This guide will not review every question in the LIHEAP Model Plan. You are encouraged to reach out to your assigned program specialist as you complete your plan with questions or to seek further clarification.

➢ Within each section of the OLDC, be aware of statutes that apply (if any) to each item in the section (e.g., Section 1 Program Components, 2605(a), 2605(b)(1) – Assurance 1, 2605 (c)(1)(C), etc.).

➢ Statutes are listed above applicable items in each section.

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General Information (Mandatory Grant Application – SF-425) This Section is required for all LIHEAP Model Plan

The first part of your LIHEAP Model Plan outlines basic information about you (the grant recipient) and your Model Plan. Pay close attention to the information you provide in the following parts.

➢ Name and contact information of person to be contacted on matters involving this application

The information in this part should match your grant recipient contact information posted on the LIHEAP Map State and Territory Contact Listing webpage or the LIHEAP Map Tribal Contact Listing webpage (see Figure 2). If it does not, contact OCS to ensure corrections are made to the website.

Figure 2: Contact Information

➢ Applicant

Your congressional district is the area in which your main office is located. Be sure to cross-check this location with the address listed in part 7b Address. The Congressional District Locator by ZIP Code can be found at: My Congressional District (census.gov).

For question 8, if you are a Tribal Consortium please include the information requested in Figure 3.

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Figure 3: Type of Applicant

➢ Authorized Certifying Official

The name or title of the authorized certifying official should match the information provided in the Delegation Letter. Otherwise, it should be the name of your grant recipient’s Governor or Tribal Chairperson.

If the Delegation Letter is from a prior year, cross-check the name you provide with the name of current Governor or Tribal Chairperson in the appropriate directory: • U.S. Governors Directory: National Governors Association (nga.org) • Tribal Chairperson Directory: Tribal Leaders Directory | Indian Affairs (bia.gov)

See the reference section of the guide for example Delegation Letters

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Section 1: Program Components This Section is required for all LIHEAP Model Plans

Types of Assistance First, you need to identify the types of assistance that will be covered under your LIHEAP Model Plan:

• Heating • Cooling • Weatherization • Sumer Crisis Assistance • Winter Crisis Assistance • Year-Round Crisis Assistance • Assurance 16

You are required to include either a heating or cooling program. You may choose to include both programs. You are also required to include a crisis program. The weatherization program and Assurance 16 are always optional. Even if you do not initially include a type of assistance, you can revise your Model Plan in the OLDC after it is approved.

The start and end dates of operation for each component should span no more than 12 months (typically between October 1 and September 30) of the FY of your LIHEAP Model Plan. If you intend to issue crisis benefits for winter only, the dates of operation should not extend into the summer months. A year-round crisis program should show dates of operation that span an entire year. Grant recipients may choose different start and end dates for their programs within the FY covered by the LIHEAP Model Plan.

The end date for the winter crisis component cannot be before March 16. The LIHEAP statute requires that crisis funds be made available at least through March 15.

Funding Allocation After you identify the types of assistance you will provide, you will need to estimate the percentage of funds used for each area of operation. When you add the percentages, it should always equal 100 percent (see Table 1). Prior year totals will prepopulate so that you can compare what was estimated in the previous FY.

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Table 1: Funding Allocation Example

Percentage Area of Operation Maximum Allocations 50% Heating Assistance N/A 10% Cooling Assistance N/A 10% Summer Crisis Assistance* N/A 10% Winter Crisis Assistance* N/A 0% Year-Round Crisis Assistance* N/A 0% Weatherization The maximum allocation for Weatherization is 15% of the total allocation. After March 31st of each year, grant recipients may request a waiver from OCS to transfer a maximum of up to 25%. If you receive a waiver, revise this information in your LIHEAP Model Plan in OLDC to account for the added percentage in Weatherization, as well as the reduction from the area you plan to take those funds. For additional details to include in the waiver request, review the LIHEAP - Code of Federal Regulations. 5% Carryover to the Following FY The maximum allocation is up to 10% from the current year. 10% Administrative and Planning Costs The maximum allocation is up to 10% of the total allocation. 5% Services to Reduce Home Energy Needs (Assurance 16) The maximum allocation is up to 5% of the total allocation.

0% Development and Implementation of Leveraging Activities State Grant recipients: The maximum allocation is the greater of 0.08% or $35,000. Tribal Grant recipients: The maximum allocation is the greater of 2% or $100. Crisis Funding must be available for crisis assistance until March 15. If the funding allocation percentage for crisis does not appear sufficient, OCS may require additional details from you prior to approval.

The percentages listed in Table 1 are examples only. Grant recipients should create a funding allocation that utilizes their LIHEAP award in the most effective way. The OCS anticipates change in the allocations initially submitted. If your estimated allocations begin to vary from your LIHEAP Model Plan, submit a revision to your plan in the OLDC by September 30 of the fiscal year. OCS encourages you to revise your Model Plan as often as needed and as early as possible.

Categorical Eligibility Categorical eligibility is used to automatically income qualify households for LIHEAP if at least one member currently receives assistance from another program.

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➢ 1.4 a. 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.

If you intend to adopt categorical eligibility, this part of Section 1 asks you to identify when households or individuals are categorically eligible based on other programs in which they participate.

Eligible programs according to the LIHEAP statute include the following:

• Temporary Assistance for Needy Families (TANF) • Supplemental Security Income (SSI) • Supplemental Nutrition Assistance Program (SNAP) • Certain Means-tested Veterans Programs

➢ 1.5 Do you automatically enroll households without a direct annual application?

If you do not require a direct annual application from each customer, be sure to provide responses in the explanation field to describe how applicants are made eligible each year through identity and household composition documentation or verification. Answering the following questions would provide OCS with an explanation of your process:

• How are customers informed of their fair hearing rights? • How is income eligibility established? • If eligibility is established through categorical eligibility, how is their level of income determined to make a benefit determination? • How is each customer’s utility information identified?

SNAP Nominal Payments There is a provision in the Farm Bill that allows a SNAP recipient to receive a higher level of benefit if the recipient also received LIHEAP. Some states decide to provide a nominal LIHEAP benefit of greater than $20, the minimum threshold established in the Farm Bill. This question is asking you to justify the nominal benefit amount, apart from the fact that it would result in greater SNAP benefits. Keep in mind that LIHEAP funds must support home energy costs or needs.

You have the discretion to choose either gross pay or net pay as the basis for determining income eligibility.

State grant recipients that select net pay should report on each customer’s income level based on gross pay in the Household Report Long Form. States must record the household's gross pay, even if that amount is not used for income eligibility purposes.

This stipulation does not apply to Tribal grant recipients who report on the short form.

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You need to identify what you will consider as countable income for the household when determining LIHEAP eligibility. This part of the section provides a list of options that you may want to take into consideration.

Some of the most considered types of income include the following:

• Social Security Administration (SSA) benefits (including or excluding Medicare deduction) • Retirement • Earned income of a child under the age of 18 (student or not a student) • Unemployment • Alimony

The Federal Government does not set a standard for what shall be included as countable income for LIHEAP eligibility determinations.

Therefore, in your LIHEAP Model Plan, please be specific as to what types of income you will count. You may want to consider similarly administered programs to ease customer application burden.

Be aware that there are very specific sources of income that cannot be counted when determining LIHEAP eligibility due to restrictions set into Federal law:

• Supplemental Nutrition Assistance Program (SNAP) benefits • Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits • Free or discounted lunches from the National School Lunch Program • Non-gambling related Tribal per capita payments (up to $2,000 per person per year) • Federal student aid for education (e.g., grants and loans to undergraduates)

Determination of Eligibility Next, you need to define which income threshold, or combination of thresholds* you will be using when determining LIHEAP eligibility:

• 150% of Federal Poverty Guidelines (FPG) • 60% of State Median Income (SMI)

You must cap income eligibility for LIHEAP’s fuel assistance and crisis benefits at: (1) no more than the greatest of 150% of the FPG or 60% of the SMI; and (2) no less than 110% of FPG.

*Note: grant recipients can use a combination of both FPG and SMI thresholds in setting income eligibility criteria.

Application Process

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Questions 1.10-1.13 ask you to describe your application process. If your process differs from the check boxes provided, please describe how you allow customers to apply in the description boxes provided.

Section 2: Heating Assistance This Section is required for all LIHEAP Model Plans if included in Section 1

In this section, you will be asked to consider the following questions and provide answers:

• Do you require an assets test? • Do you have additional or differing eligibility policies for renters or homeowners? • Do you give priority to older adults, individuals with a disability, young children, or households with high energy burdens? • What variables will you use to determine benefit levels? • What are the minimum and maximum benefits, and does this include in-kind benefits (e.g., blankets, space heaters, fans, etc.)?

➢ 2.3 Check the appropriate boxes below and describe the policies for each.

If you respond “yes” to any questions for 2.3, you must describe the differing eligibility policy. Understanding why there are differing eligibility criteria will help OCS to ensure Assurance 2 is met.

➢ 2.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.

Vulnerable populations include adults 60 years of age or older, individuals with a disability (defined by you as the grant recipient), and children under the age of 6.

Prioritizing vulnerable households is not required, but OCS encourages prioritizing these households as it helps to target benefits to those in the greatest need.

➢ 2.5 Check the variables you use to determine your benefit levels.

If you check the variables below, those variables must also be included in your attached benefit matrix. Your benefit matrix should include income, household size, and energy cost or need. The uploaded benefit matrix should use the most recently published income guidelines. The guidelines can be found on the OCS LIHEAP Policy and Guidance webpage.

You can define the variable to demonstrate that home energy costs or needs are considered. Fuel type is commonly used to demonstrate energy need. Some Tribes also consider the vulnerable status of a household member as the energy need, which is not encouraged but is allowable. Example benefit payment matrices and calculations can be found on the LIHEAP Clearinghouse.

➢ 2.6 Describe estimated benefit levels for the fiscal year for which this plan applies.

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Make sure the minimum and maximum benefit levels listed in your LIHEAP Model Plan match what is included in the uploaded benefit matrix.

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Section 3: Cooling Assistance This Section is required for all LIHEAP Model Plans if included in Section 1

In this section, you will be asked to consider the following questions and provide answers:

• Do you require an assets test? • Do you have additional or differing eligibility policies for renters or homeowners? • Do you give priority to older adults, individuals with a disability, young children, or households with high energy burdens? • What variables will you use to determine benefit levels? • What are the minimum and maximum benefits, and does this include in-kind benefits (e.g., blankets, space heaters, fans, etc.)?

➢ 3.3 Check the appropriate boxes below and describe the policies for each.

If you respond “yes” to any questions for 2.3, you must describe the differing eligibility policy. Understanding why there are differing eligibility criteria will help OCS to ensure Assurance 2 is met.

➢ 3.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.

Vulnerable populations include adults 60 years of age or older, individuals with a disability (defined by you as the grant recipient), and children under the age of 6.

Prioritizing vulnerable households is not required, but OCS encourages prioritizing these households as it helps to target benefit to those in the greatest need.

➢ 3.5 Check the variables you use to determine your benefit levels.

If you check the variables below, those variables must also be included in your attached benefit matrix. Your benefit matrix should include income, household size, and energy cost or need. The uploaded benefit matrix should use the most recently published income guidelines. The guidelines can be found on the OCS LIHEAP Policy and Guidance webpage.

You can define the variable to demonstrate that home energy costs or needs are considered. Fuel type is commonly used to demonstrate energy need. Some Tribes also consider the vulnerable status of a household member as the energy need, which is not encouraged but is allowable. Example benefit payment matrices and calculations can be found on the LIHEAP Clearinghouse.

➢ 2.6 Describe estimated benefit levels for the fiscal year for which this plan applies.

Make sure the minimum and maximum benefit levels listed in your LIHEAP Model Plan match what is included in the uploaded benefit matrix.

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Section 4: Crisis Assistance This Section is required for all LIHEAP Model Plans

Section 4 asks similar questions as Sections 2 and 3 and provides additional opportunity to describe how crisis benefits are administered.

• Provide your LIHEAP program's definition for determining a crisis. If you administer multiple crisis assistance programs (i.e., winter, summer, or year-round), include all program definitions. • What is considered a “life-threatening crisis”? • Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? • Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening situations?

Keep in mind that “crisis” and “life-threatening crisis” must be defined separately because they have different response times: 48 hours for a crisis and 18 hours for a life-threatening crisis.

• These definitions need to be different enough so that an intake worker is easily able to determine how to apply the crisis definition and how to apply the life-threatening crisis definition. • These definitions need to be objective enough so that they can be fairly applied throughout your entire service area. • These definitions should be specific enough so that the conditions and intervention timeframes for each crisis type can be documented in a customer file.

➢ 4.8 How do you handle crisis situations?

Decide how your crisis program will be designed:

• Separate Component: This process involves a separate application and, often, a different benefit level than heating or cooling assistance. • Benefit Fast Track: No separate amount of crisis funds is issued. Rather, benefits are issued to crisis customers within crisis response time frames. • Other: Be specific as to how you intend to handle crisis situations.

➢ 4.9 If you have a separate component, how do you determine crisis assistance benefits?

If you have selected “amount to resolve the crisis,” this implies up to a maximum amount. It also implies there is not a separate crisis component matrix.

➢ 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?

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➢ 4.11 Do you provide individuals with a disability the means to submit an application for crisis benefits without leaving their home?

A “No” response to 4.10 and 4.11 requires an explanation. You must provide alternative intake processes of homebound individuals or individuals with a disability, as well as ensure that services are geographically accessible.

➢ 4.12 Indicate the maximum benefit for each type of crisis assistance offered.

Verify that your responses here align with the dates of operation for the crisis component in Section 1.1.

• If you issue benefits for crisis during winter only, the dates of operation should not extend into what you consider to be the summer months. • If you issue benefits for crisis during summer, the dates of operation should include what you consider to be the summer months. • A year-round program should show dates of operation that span an entire year. You do not need to separate crisis benefits for winter and summer.

➢ 4.14 Do you provide for equipment repair or replacement using crisis funds?

Verify that your response here aligns with your response in 4.7 regarding non-working heating or cooling equipment. When a maximum benefit is under $1,000, OCS may ask if the maximum benefits provided are reasonable to cover equipment repair or replacement.

➢ 4.15 Check appropriate boxes below to indicate type(s) of assistance provided.

Verify your responses here regarding the type(s) of assistance provided in question 1.1 and the maximum benefit in question 4.12.

If providing equipment repair and replacement under crisis assistance, ensure that your policies comply with crisis assistance policies by meeting the 18-hour or 48-hour timelines. Your policies must also account for availability of interventions while processing the pre-inspection of any repair or replacement.

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Section 5: Weatherization Assistance This Section is required for all LIHEAP Model Plans if included in Section 1

In this section, you will be asked to consider the following questions and provide answers:

• Do you require an Assets test? • Do you have additional or differing eligibility policies for renters than homeowners? • Do you give priority to older adults, individuals with a disability, young children, or households with high energy burdens? • Do you use and Average Cost per Unit (ACPU)? • What are the minimum and maximum benefits, and does this include in-kind benefits (e.g., blankets, space heaters, fans, etc.)? • Who is implementing the weatherization program? • Is there a separate monitoring protocol for weatherization? • What rules are used: Department of Energy (DOE), LIHEAP, or a mix? • What weatherization measures do you provide?

➢ 5.1 Designate the income eligibility threshold used for the Weatherization component.

If you are operating your program entirely under DOE Weatherization Assistance Program (WAP) rules or mostly under DOE rules, you can indicate the income eligibility up to 200% of the FPL (the eligibility threshold for WAP) for weatherization.

➢ 5.4 Is there a separate monitoring protocol for weatherization?

If you selected “Yes” in 5.2 and “No” in 5.4, you may be contacted by OCS so that you can further explain how your weatherization program is monitored.

➢ 5.7 Do you have additional or differing eligibility policies for renters, renters living in subsidized housing, or renters with utilities included in the rent?

If you selected “No” to either of these questions about eligibility requirements for renters, you may be contacted by OCS so that you can further explain how you will ensure you have the permission of the landlord to do the work on a rented unit.

If receiving such permission of the landlord is a requirement, select “Yes” to these questions.

➢ 5.11 What LIHEAP weatherization measure do you provide?

Check the categories that apply, including rooftop solar and community solar projects.

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Section 6: Outreach This Section is required for all LIHEAP Model Plans

Outreach is an important part of a successful LIHEAP Model Plan. This section asks you to identify types of outreach activities you will conduct to ensure eligible households are made aware of all available LIHEAP assistance. This includes activities done by you (the grant recipient), as well as any applicable partners, subgrant recipients, utility vendors (using bill inserts), other community partners, or departments within your state, Tribe, or territory.

Examples include the following:

• Posters and flyers • Newspaper articles • Broadcast media announcements • Mailing inserts and brochures • Communication during intakes • Cross-program information for target groups • Web posting, email, texting, events, and social media

If you select “Other” as one of your options, please be sure to specify the other types of outreach you intend to perform.

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Section 7: Coordination This Section is required for all LIHEAP Model Plans

Do you coordinate LIHEAP with other assistance programs available to households with low incomes? Coordination may help streamline the application process. Examples include the following:

• Offering single applications that can be used for multiple programs • Accepting intake referrals to or from other programs • Sharing of an intake center so the customer only has to go to one location

This section provides a lot of examples that you can use; but, if you have other plans, please include those plans at the bottom of the section.

➢ 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.).

If you transfer some of your LIHEAP funds to another agency for weatherization (see 5.2), your response here may describe how activities between the two agencies are coordinated to ensure customers receive services as seamlessly as possible:

• Do the two agencies share subgrant recipients? • Do they exchange lists of eligible customers? • Is there a weatherization referral check box on the LIHEAP application?

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Section 8: Agency Designation This Section is required for State grant recipients and the Commonwealth of Puerto Rico

This section of the LIHEAP Model Plan asks you to describe the roles and responsibilities for LIHEAP administration. Questions include:

• How would you categorize the primary responsibility of your state agency? • How do you provide alternate outreach and intake (if you are a welfare agency) for heating, cooling, and crisis assistance? • Who determines customer eligibility? • Who processes benefit payments? • Who performs installation of weatherization measures?

If you utilize subgrant recipients or local administering agencies, you must attach a list of agencies that includes their name, address, phone number, county(-ies) served, congressional district, and UEI number. This information will be utilized by OCS to ensure customers seeking assistance are provided the appropriate contact information when using the “Do I Qualify?” tool on the LIHEAP Clearinghouse.

➢ 8.6 What is your process for selecting local administering agencies?

This question asks you to include a description of your formal subgrant recipient or local administering agency selection process. Many states sub-grant to the same local agencies because the state has a legislative exemption or state regulations identify local agencies.

Having a plan for how subgrant recipients are selected can be helpful in the event an agency closes or is no longer funded through LIHEAP. A plan can ensure continuity of program administration and help to ensure a lack of disruption of service for customers.

Questions 8.8 through 8.10 provide OCS with an understanding of changes, if any, in local subgrant recipient administration. If changes occur, OCS will ensure updates are made to the LIHEAP Clearinghouse and follow up with you regarding any potential compliance areas that may need to be addressed.

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Section 9: Energy Suppliers This Section is required for all LIHEAP Model Plans

When dealing with energy suppliers (vendors), such as utility companies and bulk fuel companies, you will need to determine how payments are made and documented for each type of assistance:

• Is payment made directly to the home energy supplier? • Will there be a confirmation letter for the customer? • How will customers be treated fairly by the utility vendor? • Are funds provided to the customer to pay the bill?

To maintain program integrity, it is recommended to pay the energy supplier and not the customer, whenever possible.

➢ 9.2 How do you notify the customer of the amount of assistance paid?

You are required to notify customers of their receipt of benefits and the amount (or their denial of services). Notification can be done in writing after the fact or verbally during the intake process. If you enroll customers automatically without an application, your response to this question should address how those customers are notified. Within your response, include the specific timeframe in which you will provide notification to your customers.

➢ 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?

➢ 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?

Your response to these questions should reference stipulations in a vendor agreement. Please ensure these stipulations are specific and measurable; try not to use vague statements as this may require additional clarification.

The final request of this section asks that you attach a copy of the template statewide vendor agreement or a policy that indicates local agreements must adhere to statewide policies and assurances.

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Section 10: Program, Fiscal Monitoring, and Audit This Section is required for all LIHEAP Model Plans

This section asks what types of audits or compliance reviews you, as the grant recipient, receive throughout the year and what types of monitoring practices you will be using. Consider questions such as:

Will your LIHEAP program be audited annually under the Single Audit Act and OMB Circular A - 133?

• What types of annual audit requirements will you have in place for local administering agencies or district offices?

How will you monitor compliance with the policies and procedures?

• Internal program and fiscal reviews? • File sampling? • Monitoring through central database?

Do you have corrective action plans in place?

• Do you have any subgrant recipients currently on a corrective action plan?

What is your monitoring schedule and protocol?

• If you do not monitor 100% of your subgrant recipients, how many do you intend to monitor in the FY for this LIHEAP Model Plan, and what does that schedule look like? • What is your risk assessment process? • What methods do you use to monitor your subgrant recipients?

Administration of LIHEAP funds will need to be monitored in compliance with the Uniform Administrative Guidance (UAG) issued by the Office of Management and Budget (OMB).

➢ 10.1 How do you ensure good fiscal accounting and tracking of funds? Be specific about tracking of grant award, tracking of expenditures, tracking vendor (benefit) refunds, fiscal reporting process, and fiscal software systems being used.

Responses to this question should include the following:

• How you track subgrant recipient awards to ensure that funds are expended within the allowable contractual period • How you track funds obligated by a second agency or department when funds are transferred for weatherization (states only) • How you track vendor refunds • How you track the obligation of funds

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• How you track the separation of funding line items by component (e.g., crisis, heating, weatherization, etc.) and by FY

Question 10.1a asks you to provide your definition for obligation, expenditure timeframe, and administrative costs. These definitions should be consistent with other federal grants you may receive and should be applied to LIHEAP in the same way you apply the definitions to your own funds.

➢ 10.2 Is your LIHEAP program audited annually under the Single Audit Act and OMB Circular A - 133?

All grant recipients (states, territories, and tribes) receiving $750,000 or more in federal funds in a single year are required to submit a Single Audit.

➢ 10.3 Describe any audit findings rising to the level of material weakness or reportable condition cited in the A-133 audits, grant recipient monitoring assessments, inspector general reviews, or other government agency reviews of the LIHEAP agency from the most recently audited fiscal year.

Any findings you list may prompt a conversation with OCS to discuss the actions taken to resolve the issues. To help alleviate the need for such a discussion, try to add sufficient details in the Action Taken column for each item you list.

➢ 10.7 Describe how you select local agencies for monitoring reviews. Attach a risk assessment if subrecipients are utilized.

Be as specific as possible when explaining how you determine monitoring for site visits and desk reviews.

Requirements of the OMB Uniform Administrative Guidance stipulate that grant recipients must perform a risk assessment of subgrant recipients in order to determine the appropriate level or type of monitoring.

➢ 10.9 How many local agencies are currently on corrective action plans?

Be aware that if you list any number other than zero, you may be contacted by OCS to discuss monitoring and training or technical assistance provided to the subgrant recipients in question. To help alleviate the need for such a discussion, you can use the space at the bottom of this section to provide more information.

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Section 11: Timely and Meaningful Public Participation This Section is required for all LIHEAP Model Plans

In this section, you will identify how you obtained input from the public in the development of your LIHEAP Model Plan. By providing the public an opportunity to comment, you are not only meeting the statutory requirements, but you are also ensuring the program is designed to meet local needs. You will select all opportunities provided as listed below:

• Public hearing(s) – Required for States • Tribal Council meeting(s) • Draft Model Plan posted to the website and available for comment • Hard copy of Model Plan available for public view (e.g., newspapers, newsletters, radio via public service announcements) and comment • Request for comments from applicants are recorded • Stakeholder consultation meeting(s) • Comments are solicited during outreach activities • Other

• State grant recipients are required to hold public hearings, which use a formal process to obtain feedback from the community.

• Tribes and territories are not required to hold public hearings, but they are required to solicit public participation.

Public participation must occur prior to the submission of your LIHEAP Model Plan. Ensure there is sufficient time for the public to review and comment on the LIHEAP Model Plan before submission. Avoid holding a public hearing one week before the plan submission, as that is likely not enough time to consider any comments received and use this information to modify your plan.

➢ 11.5 What changes did you make to your LIHEAP Model Plan as a result of public participation and solicitation of input?

The response to this question allows you to show the public how you listened to and responded to their input and allows OCS to better understand why you have elected to administer your program.

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Section 12: Fair Hearings This Section is required for all LIHEAP Model Plans

The LIHEAP statute requires that you have a process in place for fair hearings. When an application is denied or not processed in a timely manner, the applicant has the right to appeal. How do you inform applicants of their right to an appeal?

• Pamphlets • Described in their LIHEAP applications • Posters in the intake office • Included in their approval or denial letters (must not be the only communication of rights)

• Customers must be made aware of their appeal rights before the application is processed. •

• Printing appeal rights on only the approval or denial letters does not meet the requirements of the LIHEAP statute because applicants are not given enough opportunity to appeal when their applications are not processed in a timely manner or if they are not otherwise satisfied with the outcome of the application.

Be clear as to what the applicants must do as part of the appeal process. Explicitly outline the information that will be required as part of the appeal process:

• What must the applicant do to appeal, and in what time frame? • Under what circumstances can an applicant appeal? • What are the procedures for an appeal process? (How do they get this information?)

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Section 13: Reduction of Home Energy Needs This Section is required for all LIHEAP Model Plans if you included these activities in Section 1

Assurance 16 activities are used to reduce home energy needs. This section asks you to describe how you will use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and, thereby, the need for energy assistance. Be sure to identify the impact you hope these activities will make.

If you included Assurance 16 activities in the prior year’s Model Plan, identify the impact those activities had, how those outcomes were achieved, and how many households were served. There are many ways the impact of the Assurance 16 program can be measured.

➢ 13.3 Describe the impact of such activities on the number of households served in the previous Federal FY. Impact can be measured in many different ways: using logic models, data tracking systems, process evaluation, impact evaluation, number of households served versus applied, and performance management for example.

When you provide a description of the impact of the services, be sure to include more than just the number of households served:

• What difference did the services make in the life of the customer? • What were you trying to accomplish with your Assurance 16 activities? • How did you measure your success?

Outreach activities to promote LIHEAP and recruit applicants for LIHEAP assistance are not allowable under Assurance 16. For additional examples, please contact your program specialist to complete this section.

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Section 14: Leveraging Incentive Program This Section is not required, but is encouraged

The purpose of this section is to prepare, or allow the grant recipients to plan, for the Leveraging Incentive grant application for the following federal fiscal year. If HHS decides to fund the Leveraging Incentive grant program in the following federal fiscal year, but you have not completed this section of your model plan, you may not qualify for a Leveraging Incentive grant. Grant recipients are usually requested to submit a separate form to be considered for the Leveraging Incentive grant.

Collaboration with other programs could help leverage non-federal resources to best service the customers:

• Do you plan to submit an application for the leveraging Incentive program? • What non-federal resources do you plan to leverage with LIHEAP? • What are your instructions to third parties or local agencies for submitting LIHEAP leveraging resource information and retaining records?

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Section 15: Training This Section is required for all LIHEAP Model Plans

Training (one-on-one or in a group setting) is a vital part of your LIHEAP Model Plan that outlines how policies and procedures are communicated for the following:

• Grant recipient staff • Local agencies and subgrant recipients (state grant recipients only) • Utility vendors

➢ 15.2 Does your training program address fraud reporting and prevention?

Selecting “No” may prompt a conversation with OCS to discuss how you make your staff, subgrant recipients, or vendors aware of how to detect, prevent, and report fraud, waste, and abuse. To help alleviate the need for such a discussion, you can use the space at the bottom of this section to provide more information.

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Section 16: Performance Goals and Measures This Section is required for all State LIHEAP Model Plans

➢ 16.1 Describe your progress toward meeting the data collection and reporting requirements of the four required LIHEAP performance measures. Include timeframes and plans for meeting these requirements and what you believe will be accomplished in the coming federal fiscal year.

If needed, contact your assigned program specialist for technical assistance.

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Section 17: Program Integrity This Section is required for all LIHEAP Model Plans

To prevent fraud, verification is extremely important. This section asks you for information about the practices you have in place to prevent fraud, waste, and abuse. It asks about how you verify the identities of customers, as well as the validity of vendors, and how you ensure this information is accurate.

Fraud Reporting Mechanisms Describe what is available to the public to report suspected cases of waste, fraud, and abuse. • Online fraud reporting • Dedicated fraud reporting hotline • Report directly to local agency, district office, or grant recipient office • Report to state inspector general or attorney general • Forms and procedures in place for local agencies, district offices, and vendors to report fraud, waste, and abuse • Posted in local administering agencies offices • Other - Describe:

Identification Documentation Requirements How do you verify that customers are legitimately in need of LIHEAP assistance and determine that they are eligible to receive these services? This section allows you to select what type of documentation is required and from whom in the household you will be collecting the documentation.

Be sure to describe any exceptions to the policies you have outlined in this section.

Protection of Privacy and Confidentiality You handle personally identifiable information (PII) on a daily basis. Setting up best practices for privacy protection is crucial for keeping that PII safe and away from those who would use that information for fraudulent purposes. This section asks you to explain how you will keep this PII safe.

If “Other” is selected in this section, be sure to provide a description of the policy. OCS may request additional details to ensure program integrity.

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Section 18: Certification Regarding Debarment, Suspension, and other Responsibility Matters This Section is required for all LIHEAP Model Plans

Thoroughly review and certify by checking the box at the end of the section.

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Section 19: Certification Regarding Drug-free Workplace Requirements This Section is required for all LIHEAP Model Plans

Thoroughly review and certify by checking the box at the end of the section. A complete address for the Place of Performance is required. Do not enter a P.O. Box address in first line.

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Section 20: Certification Regarding Lobbying This Section is required for all State LIHEAP Model Plans

Thoroughly review and certify. This certification is required of all applicants.

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Assurances This Section is required for all LIHEAP Model Plans

Thoroughly review and certify by checking the box.

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Plan Attachments This Section is required for all LIHEAP Model Plans The following documents must be attached to this application:

• Delegation Letter is required if someone other than the Governor or Chairman certified this report. • Heating component benefit matrix, if applicable • Cooling component benefit matrix, if applicable • Minutes, notes, or transcripts of public hearing(s) • Policy Manual • Subrecipient contract • Model Plan Participation notes for Tribes

Always include a Delegation Letter. You may use the same letter from the prior year if everything on the letter (the person or title) remains unchanged and is still applicable. If the Governor or Chairman has changed from last year, you will be required to include a new Delegation Letter.

OCS will not accept your Model Plan if this letter has not been updated to reflect the change in Governor or Chairman. If there is an additional designee to sign or certify the plan, ensure that the letter includes the additional designee.

Tribal grant recipients who are currently working on developing a policy manual may include a draft of the manual as another attachment. Work on your policy manual will NOT be tied to the approval of your Model Plan.

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GrantSolutions and OLDC

To receive LIHEAP funds for the federal fiscal year, your Model Plan must be submitted in OLDC by September 1 (unless a different due date has been announced). GrantSolutions offers interactive, computer-based trainings that are available on your schedule and are geared to topics associated with grant recipient user accounts. The courses are available on the GrantSolutions Services homepage within the system. The attached flyer provides easy instructions on how to access the trainings.

In addition, OLDC within GrantSolutions has several Frequently Asked Questions (FAQs) and training modules to help grant recipients navigate between different reports and applications. A support Help Desk is available 24 hours a day, seven days a week at (844) 875-6446.

The preferred web browsers to use for accessing OLDC are Google Chrome or Mozilla Firefox. Use either in compatibility mode.

Additional training material available through GrantSolutions: • Creating an account: Create a login.gov account (grantsolutions.gov) • Federal Training Resources: Resources for grant process, application submission, and more

Once you are logged into your GrantSolutions account, you can click on the graduation cap icon on the top righthand corner of the screen to review interactive trainings.

Access the LIHEAP Model Plan Form

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To access the Model Plan form, follow these steps: 1. Click the Report Form Entry hyperlink.

2. Select “Low Income Home Energy Assistance” from the from the Program Name drop-down menu field. 3. Select your grant recipient from the Grantee Name drop-down menu field (if applicable). 4. Select “Model Plan (ACF-122)” from the Report Name drop-down menu field.

After making these three selections, the page will display any previous Model Plans you have submitted or are currently working. 5. You can select one of the existing reports by clicking on the appropriate icon in the Actions column for the corresponding fiscal year. 6. The available options in the Actions column include: a. Revise b. Report Status c. Print Latest Version (HTML) d. View Latest Report e. Clone Report

Note: The clone report option allows you to copy information from a previous LIHEAP Model Plan and use it as the foundation for the plan you intend to submit for the upcoming FY. The clone feature may not be available every year, depending on what changes were made from the prior year. Navigating the LIHEAP Model Plan

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There are a couple of ways to navigate to the various sections of the Model Plan form.

The first way is to select an action from the appropriate drop-down menu for a specific section on the Report Sections page. This will take you directly to that section of the Model Plan form. The second way is to select an option from the Report Sections drop-down menu field. This function is available when you are already on one of the pages for a section of the LIHEAP Model Plan form. At the top of each Model Plan form section page, you will see a status bar that indicates where you are in the submission and update process. You also have the following buttons available at the top and bottom of each page: Save, View/Add Attachments, Validate, and Next Section.

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Cloning a Report The Clone Report feature in OLDC allows the user to populate the fields of a current year’s form with the data from a prior year’s form. Follow the steps below to copy all information from your current year LIHEAP Model Plan form with the information from a prior year.

This process will only work if you have NOT yet initialized your current FY Model Plan.

If you already started working on the current fiscal year Model Plan, you will need to delete that Model Plan before you can go through the cloning process.

To copy all of the information from your prior federal fiscal year Model Plan into your new federal fiscal year Model Plan, follow these steps:

Step 1: Log into GrantSolutions, then select OLDC at the top right side of the screen. Click on the Report Form Entry link at the top left of the screen.

Step 2: This will take you to the Program and Grantee Selection screen.

A. In the Program Name dropdown box, select Low Income Home Energy Assistance. B. In the Grantee Name dropdown box, select the grantee name. C. In the Report Name dropdown box, select Model Plan (ACF-122).

Step 3: Click on the button located under Actions. The reporting period is 10/1/2026 – 9/30/2027. This is the FY27 LIHEAP Model Plan reporting period.

Step 4: Once you’ve clicked the button it will take you to the Clone Report screen.

A. Select the radio button next to 10/1/2025 - 9/30/2026. This is your FY26 Model Plan, and it is the information that you want to copy to your FY27 Model Plan. NOTE: The FY26 Model Plan must be in report status “Submission Accepted by CO” to clone to the current year. If you find your FY26 Plan is not in accepted status, reach out to LIHEAP@ACF.HHS.GOV, or your program specialist.

Step 5: If you have followed the above steps properly, you will see a popup message indicating that your report has been cloned successfully. Click the OK button, and your FY27 Model Plan will come up with all the information from the FY26 Model Plan prepopulated.

If you have followed the above steps properly, you will see a pop-up message indicating that your report has been cloned successfully.

1. Click the OK button. 2. Your new FY Model Plan will display with all of the information from the prior FY LIHEAP Model Plan already populated.

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3. REMEMBER TO SAVE: Once you have completed the cloning process, open any section of your new FY LIHEAP Model Plan and click the Save button at the top of the screen. This will ensure that all the data that has just been transferred into your plan will be saved.

If you close your browser session within OLDC before saving the information you cloned, you will lose all of the cloned information. When you go back to view your plan, it will be blank. Clicking the Save button in any one of the sections will save the information in all of the sections of your Model Plan.

Even though you have the option to copy your LIHEAP Model Plan from a prior year, you are expected to review every section of the information to ensure the information is up-to-date and as accurate as possible.

Revising a LIHEAP Model Plan in OLDC

This feature allows you to update information in your current year’s Model Plan after it has been submitted. To edit your current FY LIHEAP Model Plan, follow these steps:

1. Log into OLDC and select the Report Form Entry link on the OLDC Home page to navigate to the Form Selection page to select the Model Plan form. 2. Select the Revise option in the Actions column next to the reporting period dates of your current FY LIHEAP Model Plan. 3. Locate the section you wish to update. 4. Select the appropriate action from the Perform Action drop-down menu field. 5. Make your edits to the section. 6. Click the Save button, located at the bottom of the page.

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References

LIHEAP Fact Sheet: LIHEAP Fact Sheet | The Administration for Children and Families (hhs.gov)

LIHEAP Laws and Regulations: LIHEAP Statute and Regulations | The Administration for Children and Families (hhs.gov)

LIHEAP Action Transmittals, Dear Colleague Notices, and Information Memoranda: LIHEAP Policy and Guidance | The Administration for Children and Families (hhs.gov)*

*Important communications are also distributed via the LIHEAP@acf.hhs.gov email address. Please email the inbox if you are not on the distribution list.

LIHEAP Web Site: Low Income Home Energy Assistance Program (LIHEAP) | The Administration for Children and Families (hhs.gov)

LIHEAP Program Integrity: LIHEAP Program Integrity | The LIHEAP Clearinghouse (hhs.gov)

State Plans, Manuals, and Delegation Letters: LIHEAP State and Territory Plans, Manuals and Delegation Letters | The LIHEAP Clearinghouse (hhs.gov)

LIHEAP Grant recipient Resources: LIHEAP Grant Recipient Resources | The Administration for Children and Families (hhs.gov)

Tribal Plans, Manuals, and Delegation Letters: Tribal Plans, Manuals, Delegation Letters | The LIHEAP Clearinghouse (hhs.gov)

Tribal Statutes and Regulations: Tribal Statutes & Regulations | The LIHEAP Clearinghouse (hhs.gov)

LIHEAP Staff Contacts: LIHEAP Contact Information for the Division of Energy Assistance Federal Staff | The Administration for Children and Families (hhs.gov)

Low Income Home Energy Assistance Program (LIHEAP) LIHEAP Model Plan Template Note: This template cannot be submitted as an application for LIHEAP funding. The template is for demonstration purposes only. A complete LIHEAP Model Plan must be submitted in the Online Data Collection System (OLDC) to be considered for funding. Formatting within OLDC may appear different than this document.

Mandatory Grant Application SF-424 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.: 0970-0075 Expiration Date: 02/28/2027 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 2. Date Received: State Use Only: 3. Applicant Identifier: 4a. Unique Entity Identifier (UEI): 5. Date Received By State: 4b. Federal Award Identifier: 6. State Application Identifier: 7. APPLICANT INFORMATION *a. Legal Name: *b. Address: *Street 1: Street 2: *City: County: *State: Province: *County: *Zip/Postal Code: 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 the Notice of Funding Awards and on the U.S. Department of Health and Human Services’ LIHEAP contact list web page): *First Name: *Last Name: Title: Organizational Affiliation: *Telephone Number: Fax Number: *Email: *8. TYPE OF APPLICANT: a. Is the applicant a Tribal Consortium: If yes, please attach at least one of the following documents: 1. Current State-Tribe agreement between their state and the Consortium, signed by the State Chief Executive Officer (such as the Governor or the delegate) and the Consortium President; 2. Consortium letter listing the tribes, signed by the elected Tribal Chief or President of each tribe in the Consortium and signed by the Consortium President; 3. A current resolution letter from each tribe in the Consortium, signed by the elected Tribal Chief or President of that tribe. Each resolution letter needs to state that the Consortium has the tribes’ permission to apply for, and administer, LIHEAP on their behalf and needs to designate a time period for the permission or until rescinded or revoked. Catalog of Federal Domestic Assistance Number CFDA Title: 9. CFDA NUMBERS AND TITLES 10. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT: 11. AREAS AFFECTED BY FUNDING: 12. CONGRESSIONAL DISTRICTS OF APPLICANT: Page 1 of 43

13. FUNDING PERIOD: a. Start Date: b. End Date: *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 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) 17b. Signature of Authorized Certifying Official on) 17d. Email Address: 17e. Date Report Submitted (Month, Day, Year) Attach supporting documents as specified in agency instructions Page 2 of 43

Section 1 - Program Components U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) MODEL PLAN Section 1 – Program Components 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) here as requested elsewhere in this plan.) 1.1 Check which components you will operate under the LIHEAP program. (Note: You must provide information for each component designated Dates of Operation Start Date: End Date: Heating assistance ☐ ☐ Cooling assistance ☐ Weatherization assistance ☐ Summer Crisis assistance ☐ Winter Crisis assistance Year-round crisis 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% Prior year totals (auto-populate)

Percentage (%): Heating assistance Cooling assistance Summer crisis assistance Winter crisis assistance Year-round crisis assistance Weatherization assistance Carryover to the following federal fiscal year Administrative and planning costs Services to reduce home energy needs including needs assessment (Assurance 16) Used to develop and implement leverages activities TOTAL: 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. 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 Page 3 of 43

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. TANF SSI SNAP Means-tested Veterans programs Heating ☐ Yes ☐ Yes ☐ Yes ☐ Yes ☐ No ☐ No ☐ No ☐ No Cooling ☐ Yes ☐ Yes ☐ Yes ☐ Yes ☐ No ☐ No ☐ No ☐ No Crisis Weatherization ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No 1.4 a. 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? 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: $ 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 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 Page 4 of 43

☐ Loans that need to be repaid ☐ Cash gifts ☐ Savings account balance ☐ One-time lump sum payments, such as rebates or 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 ☐ 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, emailed, dropped off in-person, or faxed 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 local subgrant recipients have an online application 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: 1.11 Do you have a process for conducting and completing applications by phone: 1.12 Do you or any of your subrecipients require in person appointments in order to apply? If yes, please provide more information regarding why in-person appointments are required and in what circumstances they are required. Page 5 of 43

1.13 How can applicants submit documentation for verification? Select all that apply: ☐ In-person ☐ Mail ☐ Email ☐ Portal application ☐ Other, describe: Page 6 of 43

Section 2 - HEATING ASSISTANCE U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 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 Eligibility Threshold 2.2 Do you have additional eligibility requirements for heating assistance? ☐ Yes ☐ 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 or differing eligibility policies for: Renters? ☐ Yes ☐ No If yes, describe: Renters living in subsidized housing? ☐ Yes ☐ No If yes, describe: Renters with utilities included in the rent? ☐ Yes ☐ No If yes, describe: Do you give priority in eligibility to: Older adults? ☐ Yes ☐ No If yes, describe: Individuals with a disability? ☐ Yes ☐ No If yes, describe: Young children? ☐ Yes ☐ No If yes, describe: Households with high energy burdens? ☐ Yes ☐ No If yes, describe: Other? ☐ Yes ☐ No If yes, describe: 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. 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 7 of 43

☐ 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 Maximum Benefit 2.7 Do you provide in-kind (e.g., blankets, space heaters) or other forms of benefits? ☐ Yes ☐ 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 8 of 43

Section 3 - COOLING ASSISTANCE U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 3 – Cooling Assistance Eligibility, 2605(b)(2) - Assurance 2 3.1 Designate the income eligibility threshold used for the cooling component: Add Household size Eligibility Guideline Eligibility Threshold 3.2 Do you have additional eligibility requirements for cooling assistance? ☐ Yes ☐ No 3.3 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 or differing eligibility policies for: Renters? ☐ Yes ☐ No If yes, describe: Renters living in subsidized housing? ☐ Yes ☐ No If yes, describe: Renters with utilities included in the rent? ☐ Yes ☐ No If yes, describe: Do you give priority in eligibility to: Older adults? ☐ Yes ☐ No If yes, describe: Individuals with a disability? ☐ Yes ☐ No If yes, describe: Young children? ☐ Yes ☐ No If yes, describe: Households with high energy burdens? ☐ Yes ☐ No If yes, describe: Other? ☐ Yes ☐ No If yes, describe: Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B) 3.4 Describe how you prioritize the provision of cooling assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc. 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 ☐ Individual bill Page 9 of 43

☐ 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 Maximum Benefit 3.7 Do you provide in-kind (e.g., fans, air conditioners) and/or other forms of benefits? ☐ Yes ☐ 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 10 of 43

Section 4 - CRISIS ASSISTANCE U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 4 – Crisis Assistance Eligibility, 2605(b)(2) - Assurance 2 4.1 Designate the income eligibility threshold used for the cooling component: Add Household Eligibility Eligibility size Guideline Threshold 4.2 Provide your LIHEAP program's definition for determining a crisis. If you administer multiple crisis assistance programs (i.e. winter, summer, or year-round), include all program definitions. 4.3 What constitutes a life-threatening crisis? Crisis Requirement, 2604(c) 4.4 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? 4 8 h o u r s 4.5 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening situations? 1 8 h o u r s Crisis Eligibility, 2605(c)(1)(A) Winter Summer Year-Round Crisis Crisis 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 Do you require an assets test? ☐ ☐ ☐ Do you give priority in eligibility to: Older adults? ☐ ☐ ☐ Individuals with a disability? ☐ ☐ ☐ Young children? ☐ ☐ ☐ Households with high energy burdens? ☐ ☐ ☐ Other? ☐ ☐ ☐ 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 or cooling be medically necessary? ☐ ☐ ☐ Must the household have non-working heating or cooling ☐ ☐ ☐ equipment? Other? ☐ ☐ ☐ Do you have additional or 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: 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 ☐ Page 11 of 43

4.9 If you have a separate component, how do you determine crisis assistance benefits? Amount to resolve the crisis. Other - Describe: customers within crisis response time frames. Other - Describe: $ ☐ ☐ ☐ 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 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 Summer Crisis Year-Round Crisis Maximum Benefit Maximum Benefit Maximum Benefit $ $ $ 4.13 Do you provide in-kind (e.g., blankets, space heaters, fans) or other forms of benefits? Yes If yes, describe. ☐ No ☐ 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 ☐ ☐ ☐ 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

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related crisis situations? ☐ Yes ☐ 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 13 of 43

Section 5 - WEATHERIZATION ASSISTANCE U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 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 5.2 Do you enter into an interagency agreement to have another government agency administer a Weatherization component? ☐ Yes ☐ No 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- and 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 or differing eligibility policies for: Do you require an assets test? ☐ Yes ☐ No Do you have additional or differing eligibility policies for: Renters? ☐ Yes ☐ No Renters living in subsidized housing? ☐ Yes ☐ No Renters with utilities included in the rent? ☐ Yes ☐ No Do you give priority in eligibility to: Older adults? ☐ Yes ☐ No Individuals with a disability? ☐ Yes ☐ No Young children? ☐ Yes ☐ No Households with high energy burdens? ☐ Yes ☐ No 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 Page 14 of 43

these policies in the text field below. Benefit Levels 5.9 Do you have a maximum LIHEAP weatherization benefit or expenditure per household? ☐ Yes ☐ No If yes, what is the maximum: $ 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 ☐ Compact florescent light bulbs ☐ Community Solar projects ☐ Rooftop solar ☐ 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 15 of 43

Section 6 - Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A) U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 6 – Outreach

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 low-income programs. Execute interagency agreements with other low-income program offices to perform outreach to target groups. Web posting Email 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 16 of 43

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.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 7 – Coordination 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 or from other programs Indicate programs included: ☐ 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.

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Section 8 - Agency Designation, 2605(b)(6) - Assurance 6 U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 8 – Agency Designation 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 Agency (administers TANF, SNAP, and/or Medicaid) ☐ Economic Development Agency ☐ Other - Describe: Alternate Outreach and Intake, 2605(b)(15) - Assurance 15 If you selected "Welfare Agency" 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 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 non-compliance 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? ☐ Yes ☐ No Page 18 of 43

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 19 of 43

Section 9 - Energy Suppliers, 2605(b)(7) - Assurance 7 U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 9 – Energy Suppliers 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? 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? 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? 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 20 of 43

Section 10 - Program, Fiscal Monitoring, and Audit, 2605(b)(10) - Assurance 10 U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 10 – Program, Fiscal Monitoring, and Audit Section 10: Program, Fiscal Monitoring, and Audit, 2605(b)(10) 10.1. How do you ensure proper fiscal accounting and tracking of funds? Be specific about tracking of grant award, tracking of expenditures, tracking vendor (benefit) refunds, fiscal reporting process, and fiscal software systems being used. 10.1a Provide Definitions for the following: Obligation: Expenditures: Expenditure timeframe: Administrative 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 a 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 or district offices? Select all that apply. ☐ Local agencies and district offices are required to have an annual audit in compliance with Single Audit Act and OMB Circular A-133. ☐ Local agencies and district offices are required to have an annual audit (other than A-133). ☐ Local agencies or 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 or 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 recipient employees: ☐ Internal program review ☐ Departmental oversight ☐ Secondary review of invoices and payments ☐ Other program review mechanisms are in place. Describe: Local Administering Agencies or 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 Page 21 of 43

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. ☐ Annually ☐ Biannually ☐ Triannually ☐ Other, 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 22 of 43

Section 11 - Timely and Meaningful Public Participation, 2605(b)(12) - Assurance 12, 2605(c)(2) 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.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 11 – Timely and Meaningful Public Participation Section 11: Timely and Meaningful Public Participation, 2605(b)(12), 2605(C)(2) 11.1 How did you obtain input from the public in the development of your LIHEAP plan? Select all that apply. Note: Tribes do not need to hold a public hearing but must ensure participation through other means. ☐ Tribal Council meeting(s) ☐ Public Hearing(s) ☐ Draft Plan posted to website and available for comment. ☐ Hard copy of plan is available for public view and comment. ☐ Comments from applicants are recorded. ☐ Request for comments on draft Plan is advertised. ☐ Stakeholder consultation meeting(s) ☐ Comments are solicited during outreach activities. ☐ Other - Describe: Public Hearings, 2605(a)(2) - For States and the Commonwealth of Puerto Rico Only 11.3 List the date and location(s) that you held public hearing(s) on the proposed use and distribution of your LIHEAP funds? Date Event Description 1 2 11.4. How many parties commented on your plan at the hearing(s)? 11.5 Summarize the comments you received at the hearing(s). 11.6 What changes did you make to your LIHEAP plan as a result of public participation and solicitation of input? 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 43

Section 12 - Fair Hearings, 2605(b)(13) - Assurance 13 U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 12 – Fair Hearings Section 12: Fair Hearings, 2605(b)(13) - Assurance 13 12.1 How many fair hearings did the grant recipient have in the prior federal Fiscal Year? 12.2 How many of those fair hearings resulted in the initial decision being reversed? 12.3 Describe any policy or procedural changes made in the last federal Fiscal Year as a result of fair hearings? 12.4 Describe your fair hearing procedures for households whose applications are denied or not acted upon in a timely manner. 12.5 When and how are applicants informed of these rights? 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 24 of 43

Section 13 - Reduction of home energy needs, 2605(b)(16) - Assurance 16 U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01 Administration for Children and Families OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 13 – Reduction of Home Energy Needs Section 13: Reduction of Home Energy Needs, 2605(b)(16) - Assurance 16 13.1 Describe how you use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and thereby the need for energy assistance? 13.2 How do you ensure that you don't use more than 5% of your LIHEAP funds for these activities? 13.3 Describe the impact of such activities on the number of households served in the previous federal Fiscal Year? Impact can be measured in many different ways: using logic models, data tracking systems, process evaluation, impact evaluation, number of households served versus applied, and performance management for example. 13.4 Describe the level of direct benefits provided to those households in the previous federal Fiscal Year. 13.5 How many households received these services? 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 25 of 43

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.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 14 – Leveraging Incentive Program 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 or local agencies for submitting LIHEAP leveraging resource information and retaining records. 14.3 For each type of resource 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 benefit? What is the source(s) of the resource? How will the resource be integrated and coordinated with LIHEAP? 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 26 of 43

Section 15 - Training U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM LIHEAP) MODEL PLAN Section 15 – Training Section 15: Training 15.1 Describe the training you provide for each of the following groups: a. Grant recipient Staff: ☐ Formal training provided virtually, on-site, and/or formal training conference How often? ☐ Annually ☐ Biannually ☐ As needed ☐ Other - Describe: ☐ Employees are provided with policy manual ☐ Other - Describe: b. Local Agencies: ☐ Formal training provided virtually, on-site, and/or formal training conference How often? ☐ Annually ☐ Biannually ☐ As needed ☐ Other - Describe: ☐ Employees are provided with policy manual ☐ Other - Describe: c. Vendors ☐ Formal training provided virtually, on-site, and/or formal training conference How often? ☐ Annually ☐ Biannually ☐ As needed ☐ Other - Describe: ☐ Policies communicated through vendor agreements ☐ Policies are outlined in a vendor manual 15.2 Does your training program address fraud reporting and prevention? ☐ Yes ☐ No Page 27 of 43

Section 16 - Performance Goals and Measures, 2605(b) U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 16 – Performance Goals and Measures Section 16: Performance Goals and Measures, 2605(b) - Required for States Only 16.1 Describe your progress toward meeting the data collection and reporting requirements of the four required LIHEAP performance measures. Include timeframes and plans for meeting these requirements and what you believe will be accomplished in the coming federal Fiscal Year. 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 28 of 43

Section 17 - Program Integrity, 2605(b)(10) U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 17 – Program Integrity Section 17: Program Integrity, 2605(b)(10) 17.1 Fraud Reporting Mechanisms a. Describe all mechanisms available to the public for reporting cases of suspected waste, fraud, and abuse. Select all that apply. ☐ Online Fraud Reporting ☐ Dedicated Fraud Reporting Hotline ☐ Report directly to local agency/district office or Grant recipient office ☐ Report to State Inspector General or Attorney General ☐ Forms and procedures in place for local agencies/district offices and vendors to report fraud, waste, and abuse ☐ Posted in local administering agencies offices Other - Describe: b. Describe strategies in place for advertising the above referenced resources. Select all that apply ☐ Printed outreach materials ☐ Addressed on LIHEAP application ☐ Website ☐ Printed outreach materials Other - Describe: 17.2. Identification Documentation Requirements a. Indicate which of the following forms of identification are required or requested to be collected from LIHEAP applicants or their household members. Type of Identification Collected Collected from Whom? Applicant Only All Adults in Household All Household Members Social Security card is photocopied and retained ☐ Required ☐ Required ☐ Required ☐ Requested ☐ Requested ☐ Requested Social Security number (Without actual Card) ☐ Required ☐ Required ☐ Required ☐ Requested ☐ Requested ☐ Requested Government-issued identification card (i.e., driver's license, state ID, Tribal ID, passport, etc.) ☐ Required ☐ Required ☐ Required ☐ Requested ☐ Requested ☐ Requested Other Applicant Only Required Applicant Only Requested All Adults in Household Required All Adults in Household Requested All Household Members Required All Household Members Requested 1 ☐ ☐ ☐ ☐ ☐ ☐ b. Describe any exceptions to the above policies. 17.3 Identification Verification Describe what methods are used to verify the authenticity of identification documents provided by clients or household members. Select all that apply ☐ Describe what methods are used to verify the authenticity of identification documents provided by clients or household members. Select all that apply ☐ Verify SSNs with Social Security Administration ☐ Match SSNs with death records from Social Security Administration or state agency ☐ Match SSNs with state eligibility/case management system (e.g., SNAP, TANF) ☐ Match with state Department of Labor system Page 29 of 43

☐ Match with state and/or federal corrections system ☐ Match with state child support system ☐ Verification using private software (e.g., The Work Number) ☐ In-person certification by staff (for tribal grant recipients only) ☐ Match SSN/Tribal ID number with tribal database or enrollment records (for tribal grant recipients only) ☐ Other - Describe: 17.4. Citizenship or Legal Residency Verification What are your procedures for ensuring that household members are U.S. citizens or qualified non-citizens who are qualified to receive LIHEAP benefits? Select all that apply. ☐ Clients sign an attestation of citizenship or U.S. citizen or qualified non-citizen. ☐ Client's submission of Social Security cards is accepted as proof of U.S. citizen or qualified non-citizen. ☐ Non-citizens must provide documentation of immigration status. ☐ Citizens must provide a copy of their birth certificate, naturalization papers, or passport. ☐ Non-citizens are verified through the SAVE system. ☐ Tribal members are verified through Tribal enrollment records/Tribal ID card. ☐ Other - Describe: 17.5. Income Verification What methods does your agency utilize to verify household income? Select all that apply. ☐ Require documentation of income for all adult household members ☐ Pay stubs ☐ Social Security award letters ☐ Bank statements ☐ Tax statements ☐ Zero income statements ☐ Unemployment Insurance letters ☐ Other - Describe: ☐ Computer data matches: ☐ Income information matched against state computer system (e.g., SNAP, TANF) ☐ Proof of unemployment benefits verified with state Department of Labor ☐ Social Security income verified with SSA ☐ Utilize state directory of new hires ☐ Other - Describe: 17.6. Protection of Privacy and Confidentiality Describe the financial and operating controls in place to protect client information against improper use or disclosure. Select all that apply. ☐ Policy in place prohibiting release of information without written consent ☐ Grant recipient LIHEAP database includes privacy/confidentiality safeguards. ☐ Employee training on confidentiality for: ☐ Grant recipient employees ☐ Local agencies/district offices ☐ Employees must sign confidentiality agreement ☐ Grant recipient employees ☐ Local agencies/district offices ☐ Physical files are stored in a secure location. ☐ Electronic files are protected in a secure location. ☐ Other - Describe: 17.7. Verifying the Authenticity What policies are in place for verifying vendor authenticity? Select all that apply. ☐ All vendors must register with the state/tribe. ☐ All vendors must supply a valid SSN or TIN/W-9 form. Page 30 of 43

☐ Vendors are verified through energy bills provided by the household. ☐ Grant recipient and/or local agencies/district offices perform physical monitoring of vendors. ☐ Other - Describe and note any exceptions to policies above: 17.8. Benefits Policy - Gas and Electric Utilities What policies are in place to protect against fraud when making benefit payments to gas and electric utilities on behalf of clients? Select all that apply. ☐ Applicants required to submit proof of physical residency. ☐ Applicants must submit current utility bill. ☐ Data exchange with utilities that verifies: ☐ Account ownership ☐ Consumption ☐ Balances ☐ Payment history ☐ Account is properly credited with benefit ☐ Other - Describe: ☐ Centralized computer system/database tracks payments to all utilities. ☐ Centralized computer system automatically generates benefit level. ☐ Separation of duties between intake and payment approval. ☐ Payments coordinated among other energy assistance programs to avoid duplication of payments. ☐ Payments to utilities and invoices from utilities are reviewed for accuracy. ☐ Computer databases are periodically reviewed to verify accuracy and timeliness of payments made to utilities. ☐ Direct payment to households are made in limited cases only. ☐ Procedures are in place to require prompt refunds from utilities in cases of account closure. ☐ Vendor agreements specify requirements selected above and provide enforcement mechanism. ☐ Other - Describe: 17.9. Benefits Policy - Bulk Fuel Vendors What procedures are in place for averting fraud and improper payments when dealing with bulk fuel suppliers of heating oil, propane, wood, and other bulk fuel vendors? Select all that apply. ☐ Vendors are checked against an approved vendor list. ☐ Centralized computer system/database is used to track payments to all vendors. ☐ Clients are relied on for reports of non-delivery or partial delivery. ☐ Two-party checks are issued naming client and vendor. ☐ Direct payment to households is made in limited cases only. ☐ Vendors are only paid once they provide a delivery receipt signed by the client. ☐ Conduct monitoring of bulk fuel vendors. ☐ Bulk fuel vendors are required to submit reports to the grant recipient. ☐ Vendor agreements specify requirements selected above, and provide enforcement mechanism ☐ Other - Describe: 17.10. Investigations and Prosecutions Describe the Grant recipient's procedures for investigating and prosecuting reports of fraud, and any sanctions placed on clients, staff, or vendors found to have committed fraud. Select all that apply. ☐ Refer to state Inspector General. ☐ Refer to local prosecutor or state Attorney General. ☐ Refer to U.S. DHHS Inspector General (including referral to OIG hotline). ☐ Local agencies/district offices or Grant recipient conduct investigation of fraud complaints from public. Page 31 of 43

☐ Grant recipient attempts collection of improper payments. If so, describe the recoupment process. ☐ Clients found to have committed fraud are banned from LIHEAP assistance. For how long is a household banned? ☐ Contracts with local agencies require that employees found to have committed fraud are reprimanded and/or terminated. ☐ Vendors found to have committed fraud may no longer participate in LIHEAP. ☐ 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 32 of 43

Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 18 – Certification Regarding Debarment, Suspension, and Other Responsibility Matters Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions Instructions for Certification 1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction. 7. The prospective primary participant further agrees by submitting this proposal that it will include the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transaction,'' provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant Page 33 of 43

may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 10. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions (1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and (d) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions Instructions for Certification 1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. 2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances. Page 34 of 43

4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 5. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. 6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled ``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,'' without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. Certification Regarding Debarment, Suspension, Ineligibility a Voluntary Exclusion--Lower Tier Covered Transactions (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal By checking this box, the prospective primary participant is providing the certification set out above. ☐

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Section 19: Certification Regarding Drug-Free Workplace Requirements U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 19 – Certification Regarding Drug-Free Workplace Requirements Section 19: Certification Regarding Drug-Free Workplace Requirements This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATEWIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central point is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201. Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification) 1. By signing and/or submitting this application or grant agreement, the grant recipient is providing the certification set out below. 2. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grant recipient knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act. 3. For grant recipients other than individuals, Alternate I applies. 4. For grant recipients who are individuals, Alternate II applies. 5. Workplaces under grants, for grant recipients other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If the grant recipient does not identify the workplaces at the time of application, or upon award, if there is no application, the grant recipient must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grant recipient's drug-free workplace requirements. 6. Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios). 7. If the workplace identified to the agency changes during the performance of the grant, the grant recipient shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five). Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grant recipients' attention is called, in particular, to the following definitions from these rules: Controlled substance means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15); Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes; Criminal drug statute means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance; Page 36 of 43

Employee means the employee of a grant recipient directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grant recipient's payroll. This definition does not include workers not on the payroll of the grant recipient (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grant recipient's payroll; or employees of subrecipients or subcontractors in covered workplaces). Certification Regarding Drug-Free Workplace Requirements Alternate I. (Grant recipients Other Than Individuals) The grant recipient certifies that it will or will continue to provide a drug-free workplace by:, (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grant recipient's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing an ongoing drug-free awareness program to inform employees about -­ (1) The dangers of drug abuse in the workplace; (2) The grant recipient's policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will -­ (1) Abide by the terms of the statement; and (2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; (e) Notifying the agency in writing, within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant; (f)Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d)(2), with respect to any employee who is so convicted -(1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). (B) The grant recipient may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: Place of Performance (Street address, city, county, state, zip code) * Address Line 1, do not enter P.O. Box Address Line 2 Address Line 3 Page 37 of 43

*City *State *Zip Code Check if there are workplaces on file that are not identified here. Alternate II. (Grant recipients Who Are Individuals) (a) The grant recipient certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant; (b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant. [55 FR 21690, 21702, May 25, 1990] ☐ By checking this box, the prospective primary participant is providing the certification set out above. Page 38 of 43

Section 20: Certification Regarding Lobbying U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Section 20 – Certification Regarding Lobbying Section 20: Certification Regarding Lobbying The submitter of this application certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, ``”“Disclosure Form to Report Lobbying,’’ in accordance with its instructions (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Statement for Loan Guarantees and Loan Insurance The undersigned states, to the best of his or her knowledge and belief, that: If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,’’ in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. ☐ By checking this box, the prospective primary participant is providing the certification set out above. Page 39 of 43

Section 21: Assurances U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Assurances (1) use the funds available under this title to— (A) conduct outreach activities and provide assistance to low-income households in meeting their home energy costs, particularly those with the lowest incomes that pay a high proportion of household income for home energy, consistent with paragraph (5); (B) intervene in energy crisis situations; (C) provide low-cost residential weatherization and other cost-effective energy-related home repair; and (D)plan, develop, and administer the State's program under this title including leveraging programs, and the State agrees not to use such funds for any purposes other than those specified in this title; (2) make payments under this title only with respect to-­ (A) households in which one or more individuals are receiving-- (i)assistance under the State program funded under part A of title IV of the Social Security Act; (ii) supplemental security income payments under title XVI of the Social Security Act; (iii) food stamps under the Food Stamp Act of 1977; or (iv) payments under section 415, 521, 541, or 542 of title 38, United States Code, or under section 306 of the Veterans' and Survivors' Pension Improvement Act of 1978; or (B) households with incomes which do not exceed the greater of ­ (i) an amount equal to 150 percent of the poverty level for such State; or (ii) an amount equal to 60 percent of the State median income; (except that a State may not exclude a household from eligibility in a fiscal year solely on the basis of household income if such income is less than 110 percent of the poverty level for such State, but the State may give priority to those households with the highest home energy costs or needs in relation to household income. (3) conduct outreach activities designed to assure that eligible households, especially households with elderly individuals or disabled individuals, or both, and households with high home energy burdens, are made aware of the assistance available under this title, and any similar energy-related assistance available under subtitle B of title VI (relating to community services block grant program) or under any other provision of law which carries out programs which were administered under the Economic Opportunity Act of 1964 before the date of the enactment of this Act; coordinate its activities under this title with similar and related programs administered by the Federal Government and such State, particularly low-income energy-related programs under subtitle B of title VI (relating to community services block grant program), under the supplemental security income program, under part A of title IV of the Social Security Act, under title XX of the Social Security Act, under the low-income weatherization assistance Page 40 of 43

program under title IV of the Energy Conservation and Production Act, or under any other provision of law which carries out programs which were administered under the Economic Opportunity Act of 1964 before the date of the enactment of this Act; (5) provide, in a timely manner, that the highest level of assistance will be furnished to those households which have the lowest incomes and the highest energy costs or needs in relation to income, taking into account family size, except that the State may not differentiate in implementing this section between the households described in clauses 2(A) and 2(B) of this subsection; (6) to the extent it is necessary to designate local administrative agencies in order to carry out the purposes of this title, to give special consideration, in the designation of such agencies, to any local public or private nonprofit agency which was receiving Federal funds under any low-income energy assistance program or weatherization program under the Economic Opportunity Act of 1964 or any other provision of law on the day before the date of the enactment of this Act, except that ­ (A) the State shall, before giving such special consideration, determine that the agency involved meets program and fiscal requirements established by the State; and (B) if there is no such agency because of any change in the assistance furnished to programs for economically disadvantaged persons, then the State shall give special consideration in the designation of local administrative agencies to any successor agency which is operated in substantially the same manner as the predecessor agency which did receive funds for the fiscal year preceding the fiscal year for which the determination is made; (7) if the State chooses to pay home energy suppliers directly, establish procedures to -­ (A) notify each participating household of the amount of assistance paid on its behalf; (B) 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 made by the State under this title; (C) assure that the home energy supplier will provide assurances that any agreement entered into with a home energy supplier under this paragraph will contain provisions to assure that no household receiving assistance under this title will be treated adversely because of such assistance under applicable provisions of State law or public regulatory requirements; and (D) ensure that the provision of vendor payments remains at the option of the State in consultation with local grant recipients and may be contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible households, including providing for agreements between suppliers and individuals eligible for benefits under this Act that seek to reduce home energy costs, minimize the risks of home energy crisis, and encourage regular payments by individuals receiving financial assistance for home energy costs; (8) provide assurances that, (A) the State will not exclude households described in clause (2)(B) of this subsection from receiving home energy assistance benefits under clause (2), and (B) the State will treat owners and renters equitably under the program assisted under this title; (9) provide that-­ (A) the State may use for planning and administering the use of funds under this title an amount not to exceed 10 percent of the funds payable to such State under this title for a fiscal year; and (B) the State will pay from non-Federal sources the remaining costs of planning and administering the program assisted under this title and will not use Federal funds for such Page 41 of 43

remaining cost (except for the costs of the activities described in paragraph (16)); (10) provide that such fiscal control and fund accounting procedures will be established as may be necessary to assure the proper disbursal of and accounting for Federal funds paid to the State under this title, including procedures for monitoring the assistance provided under this title, and provide that the State will comply with the provisions of chapter 75 of title 31, United States Code (commonly known as the "Single Audit Act"); (11) permit and cooperate with Federal investigations undertaken in accordance with section 2608; (12) provide for timely and meaningful public participation in the development of the plan described in subsection (c); (13) provide an opportunity for a fair administrative hearing to individuals whose claims for assistance under the plan described in subsection (c) are denied or are not acted upon with reasonable promptness; and (14) cooperate with the Secretary with respect to data collecting and reporting under section 2610. (15) * beginning in fiscal year 1992, provide, in addition to such services as may be offered by State Departments of Public Welfare at the local level, outreach and intake functions for crisis situations and heating and cooling assistance that is administered by additional State and local governmental entities or community-based organizations (such as community action agencies, area agencies on aging and not-for­ profit neighborhood-based organizations), and in States where such organizations do not administer functions as of September 30, 1991, preference in awarding grants or contracts for intake services shall be provided to those agencies that administer the low-income weatherization or energy crisis intervention programs. * This assurance is applicable only to States, and to territories whose annual regular LIHEAP allotments exceed $200,000. Neither territories with annual allotments of $200,000 or less nor Indian tribes/tribal organizations are subject to Assurance 15. (16) use up to 5 percent of such funds, at its option, to provide services that encourage and enable households to reduce their home energy needs and thereby the need for energy assistance, including needs assessments, counseling, and assistance with energy vendors, and report to the Secretary concerning the impact of such activities on the number of households served, the level of direct benefits provided to those households, and the number of households that remain unserved. ☐ By checking this box, the prospective primary participant is providing the certification set out above. Page 42 of 43

Plan Attachments U.S. Department of Health and Human Services August 1987, revised 05/92, 02/95, Administration for Children and Families 03/96, 12/98, 11/01 OMB Clearance No.: 0970-0075 Expiration Date: 02/28/2027 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) MODEL PLAN Plan Attachments The following documents must be attached to this application • Delegation Letter is required if someone other than the Governor or Chairman Certified this Report. • Heating component benefit matrix, if applicable • Cooling component benefit matrix, if applicable • Minutes, notes, or transcripts of public hearing(s). Optional: Policy Manual Optional: Subrecipient contract Optional: Model Plan Participation notes for Tribes Page 43 of 43

AT#: LIHEAP-AT-2026-4

DATE: June 10, 2026

TO : All LIHEAP Grant Recipients

SUBJECT : Model Plan Application for LIHEAP Funding for Federal Fiscal Year 2027 (FY27) (Application deadline Tuesday, September 1, 2026)

ATTACHMENT(S) : 1. How to Use the Clone Report Feature in OLDC to Submit a New FY27 LIHEAP Plan. 2. LIHEAP Model Plan Reference Guide. 3. FY27 Model Plan Form

PURPOSE: To provide Low Income Home Energy Assistance (LIHEAP) grant recipients with instructions for how to apply online for federal Fiscal Year 2027 (FY27) LIHEAP funding, confirm the September 1, 2026, LIHEAP Model Plan submission deadline, and remind grant recipients

they can “clone” or pre-populate their prior data into a new Plan submission to reduce administrative reporting burden.

BACKGROUND: States, the District of Columbia, territories, and tribes or tribal organizations that wish to administer LIHEAP must submit an application for funds by September 1st (or the date issued by the Office of Community Services (OCS)) each FY, covering a grant period of October 1 through September 30. Section 2605(c)(3) of the federal LIHEAP statute (42 U.S.C. § 8624(c)(1)) provides that the Secretary shall make available a model LIHEAP Plan, which may be used to prepare the application required under sections 2605(a)(1) and (c)(1) (42 U.S.C. § 8624(a)(1) and (c)(1)).

OCS has the responsibility to review and accept LIHEAP Model Plan submissions on behalf of

the U.S. Department of Health and Human Services’ (HHS) Administration for Children and

Families (ACF). The Office of Management and Budget approved ACF’s LIHEAP Model Plan form under clearance number 0970-0075 is effective through February 28, 2027.

The deadline for the FY27 Plan is Tuesday, September 1, 2026 .

Grant recipients must submit the LIHEAP Model Plan via the Online Data Collection (OLDC), located within GrantSolutions , each FY in order to receive LIHEAP funding allocation.

For FY27, LIHEAP grant recipients can “clone” or pre-populate their FY26 data into a new Plan, but they must follow the application process outlined below.

All grant recipients must complete the entire LIHEAP Model Plan for FY27 in OLDC. Grant recipients can transfer information from the FY26 LIHEAP Plan (prior plan) into the new Plan by using the “Clone Report” feature in OLDC. Attachment 1 provides step-by-step instructions for how to use the “Clone Report” feature.

After transferring prior year information into the new Plan, at a minimum, grant recipients must update responses to the following sections:

SF-424 Mandatory Grant Application section — Fields 1.d., 7.d. (this section will be used as the official point of contact for the public director of State and Territory Grant Recipient Contacts and Tribal Grant Recipient Contacts ), 13.a., and 13b. Funding Period, and fields 16 and 17 Authorized Official through the attached Letter of Delegation;

Section 1-Program Components, 2605(b)(1)-Question 1.1 Dates of Operations Question 1.2 Estimated Funding Allocations;

Section 2—Heating Assistance, 2605(b)(2) — Question 2.1 Eligibility Threshold; Section 3—Cooling Assistance, 2605(b)(2) — Question 3.1 Eligibility Threshold; Section 4 — Crisis Assistance, 2605(c) — Question 4.1 Eligibility Threshold;

Section 5—Weatherization Assistance, 2605(b)(2) — Question 5.1 Eligibility Threshold;

Section 8 — Agency Designation, 2605(b)(6)-Assurance 6 — Question 8.8. This section is required for state grant recipients and the Commonwealth of Puerto Rico only;

Section 10 — Program, Fiscal Monitoring, and Audit, 2605(b)(10)-Assurance 10 — Questions 10.3, 10.9;

Section 11 — Timely and Meaningful Public Participation, 2605(b)(12), 2605(c)(2) — Questions 11.1-11.5;

Section 12 — Fair Hearings, 2605(b)(10) — Questions 12.1-12.3;

Section 13 — Reduction of home energy needs, 2605(b)(16) — Questions 13.1-13.5; and

Section 16 — Performance Goals and Measures, 2605(b). This section is required of state grant recipients only and optional for other grant recipients.

Attach supporting documentation or provide links to supporting documents online, as needed, such as policies and procedures.

The LIHEAP Model Plan includes an optional section (Section 14) to explain possible leveraging activities the grant recipient may take during FY27. Completing this section is one requirement to receive a separate leveraging grant, if funding becomes available. However, OCS awards leveraging grants in the federal FY following the year the grant recipient conducted the leveraging activities. Therefore, if funding becomes available in FY27 for leveraging, OCS would award leveraging grants in FY27 based upon a separate leveraging report that would be reconciled against the responses in the FY26 LIHEAP Model Plan for leveraging activities that took place in FY26. Similarly, if leveraging funding becomes available in FY28, OCS would award leveraging grants in FY28 based upon FY27 LIHEAP Model Plan. OCS last awarded leveraging grants in FY12 and has no estimate for when federal leveraging grants may become available again. However, grant recipients are encouraged to complete this section if they intend to leverage non-federal funds to assist LIHEAP bill payment or weatherization assistance households so that the public and all interested parties can review and comment on the grant recipient’s efforts.

The statute requires that complete LIHEAP Plans MUST include the LIHEAP Household Report for the previous federal fiscal year regarding assisted households and households applying for assistance. Therefore, in order for the FY27 LIHEAP Plan to be accepted, the FY26 Household Report must be submitted along with the LIHEAP Plan in OLDC.

The LIHEAP statute requires the Secretary to collect data on the number and income levels of households assisted and the following additional household data:

Number of assisted households with at least one young child;

Number and income levels of households applying for LIHEAP assistance; and

Number of assisted households with at least one or more individuals who are 60 years or older or disabled.

States, the District of Columbia, and territories with regular allotments of $200,000 or more must collect this data on their applicant and recipient households in order to submit the data on the Household Report (Long Form — ACF 121).

All tribal grantees, and territories with regular allotments of less than $200,000, are required to submit only information on the number of households served in each of its program components (i.e., heating, cooling, crisis, and weatherization on the Household Report Short Form, ACF - 120).

The FY 2026 Household Report must be submitted no later than September 1, 2026 , with at least estimates provided. If only estimates are provided, or changes to final numbers occur, the FY 2026 Household Report must be resubmitted no later than December 31, 2026 , with final data. All grantees must submit the Household Report through OLDC.

Section III: Estimated Use of Funds in the required Quarter 3 report includes the information from the previously required Carryover and Reallotment Report (CRR). This

means: the LIHEAP CRR will no longer be a required report in its previous format. The required data will be captured in the LIHEAP Quarterly Report . Two key data elements from the

CRR are required explicitly by the federal LIHEAP statute. The data elements include Q3 estimates of how much the grant recipient requests HHS set aside to be carried over from the current federal fiscal year into the next federal fiscal year. The data elements include estimates of how much the grant recipient anticipates having to return to HHS as unobligated and available for HHS to reallot in the next federal fiscal year, as well as includes a required

“remarks” field for grant recipients to explain why they are requesting to carryover funds and how they intend to use them in the next year, as required by the LIHEAP statute. Section III of Q4 report asks for the final carryover and reallotment amounts for that year and remarks.

The LIHEAP statute (42 U.S.C. § 8626) requires grant recipients to submit information necessary for administration of carryover and reallotment. Pursuant to this authority, HHS conditions the release of grant awards upon submission of the Carryover and Reallotment information provided through the Quarterly Report.

The assurances displayed in the Section 21 of the LIHEAP Model Plan are from the federal LIHEAP statute (42 U.S.C. § 8624(b)(1)-(16)). LIHEAP regulations at 45 CFR § 96.10(b) require that the 16 assurances (15 for tribes) in the LIHEAP statute be certified by the grant recipient’s Chief Executive Officer or “by an individual authorized to make such certifications on behalf of the Chief Executive Officer.” For the LIHEAP Model Plan to be accepted, please be sure that the governor or tribal chairperson (1) certifies the assurances or (2) has specifically delegated authority to “certify” the LIHEAP Assurances to another person or position (not merely the

department or agency). The grant recipient must attach a delegation letter to the LIHEAP Model

Plan in OLDC, and the letter must explicitly specify that the individual is authorized to certify the federal LIHEAP assurances.

In addition to the LIHEAP Model Plan, grant recipients must also complete or update the Mandatory Grant Application SF-424, which is the first section of the LIHEAP Model Plan in OLDC. The person that is designated to “certify to the LIHEAP assurances” must have an OLDC account and, while logged into their OLDC account, must be the person that clicks the “Certify” and “Click to Sign” buttons for the LIHEAP Model Plan in OLDC. Therefore, if the governor or tribal chairperson chooses not to designate someone else to sign the LIHEAP assurances, then the governor or tribal chairperson must have their own account and “certify” the FY27 LIHEAP Model Plan in OLDC.

States, the District of Columbia, and territories receiving more than $200,000 must describe in their new FY27 Plan how they will carry out assurance 15 (section 2605(b)(15)) of the LIHEAP Act, see 42 U.S.C. § 8624(b)(15)). Assurance 15 requires such grant recipients to offer LIHEAP intake services in addition to those available through agencies also administering the Temporary Assistance for Needy Families (TANF) program. An attachment detailing this plan may be added or entered in any of the fields in Sections 8.2, 8.3, and 8.4.

Section 18 — All LIHEAP grant recipients must agree to the Certification Regarding Debarment, Suspension, and Other Responsibility Matters.

Section 19 — All LIHEAP grant recipients must submit the Certification Regarding Drug-Free Workplace Requirements unless a state has submitted a statewide assurance to the S. Department of Health and Human Services. When completing this certification, be sure to enter the grant recipient’s physical address in the appropriate fields. No post office (P.O.) boxes allowed.

Section 20 —All states must file the Certification Regarding Lobbying certifying they will not use federal funds for And, if applicable, complete Form LLL, which discloses lobbying payments if they use non-federal funds to lobby in connection with the award. Tribes and tribal organizations with awards less than $100,000 are not required to complete the Certification Regarding Lobbying.

Assurances—All LIHEAP grant recipients must agree to the assurances at 42 S.C. § 8624(b)(1)-(16), unless otherwise exempted by law.

The LIHEAP Plan form in OLDC, Sections 18-21, incorporates all the above certifications. Please ensure that the certification checkbox is marked in the required certification section.

States and Territories: The federal law requires states and territories to conduct public hearings on the proposed use and distribution of funds as outlined in the

FY27 LIHEAP Plan (42 U.S.C. § 8624(a)(2)). Grant recipients should follow their own state and territorial procedures for public hearings.

Tribes: No hearing is required of tribal grant recipients. However, tribal grant recipients are required to obtain timely and meaningful public participation or input from their communities regarding their draft or proposed FY27 LIHEAP Plan (42 U.S.C. § 8624(b)(12)). This may include some combination of web postings, public service announcements, comments by email or phone, stakeholder calls, surveys, Tribes must follow their tribal-wide rules for public participation that they would use with their own tribal funding. Note: Timely means that the public participation process must be completed in advance of and prior to the submission of the Plan to get public comments and allow enough time for internal review.

The following documents must be attached to the application in OLDC to be considered complete:

Delegation Letter (required if someone other than the Chief Executive, g., a governor or tribal chairperson certified the FY Plan in OLDC).

Benefit matrix or matrices showing at least three varying measures (income, household size, and home energy costs or needs) to determine benefit types and amounts of assistance, such as heating, cooling, and crisis assistance. Use the applicable new income guidelines published here . See 42 U.S.C. § 8624(b)(5) for the benefit assurance and 42 S.C. § 8622(4) for the definition of “highest home energy needs”)

Minutes, notes, or transcripts of public hearing(s) (states and territories only).

Evidence of Public Participation for Tribes (Tribes).

Optional: Policy Manual, Subrecipient

OCS encourages directly funded tribes that receive smaller annual LIHEAP grants to consider joining an existing consortium in their state(s) or forming a consortium with neighboring tribes to reduce the administrative burden of the LIHEAP Plan submission and the required reports. For information on how to form or join a consortium, inquire with your federal LIHEAP Office . This information is available under Section B of the LIHEAP Grantee Resource Guide (formerly known as the Tribal Manual).

Submission Deadline Extension : If a grant recipient anticipates needing an extension beyond the September 1, 2026 , Plan submission deadline, the grant recipient must submit a letter requesting a deadline extension. The letter must be uploaded as an attachment to an “initialized” FY27 Plan in OLDC. The request must provide a specific, reasonable alternative date

and a brief explanation of the reason for needing an extension. Tribal grant recipients must obtain written agreement of the extension date from the state(s) in which the tribe’s service areas are located. The state’s concurrence must also be included as an attachment to the initialized 2027 Plan. Extension requests must be submitted prior to Tuesday, September 1, 2026.

Follow-up Action on Plan Submissions : Upon receipt of FY27 Plans, OCS staff will review the Plans and either reject the Plan back to the grant recipient via OLDC or accept the plan in OLDC. Grant recipients whose plans are “accepted” in OLDC have no further action to take on the Plan. Grant recipients whose plans are “rejected” in OLDC must take immediate action to edit their Plans according to the comments in the OLDC review sections of the Plan and resubmit the edited Plan to OCS within the deadline indicated in the Plan review remarks in OLDC. The federal LIHEAP regulations require that this editing process must be completed no later than December 15, 2026. This deadline is only regarding edits and attachments that are necessary to resolve missing or inadequate information in the original Plan submission.

OCS will only issue FY27 LIHEAP funding upon an appropriation from Congress; apportionment from the Office of Management and Budget (OMB); and the receipt and acceptance of a LIHEAP Plan submission that meets statutorily required information. All LIHEAP grant recipients have an ongoing responsibility throughout the grant period to submit revised Plans and reports, as needed, to reflect changes to ensure HHS ACF OCS has final, actual program data.

INQUIRIES: For questions regarding this Model Plan guidance, please contact: Kate Thomas

Senior Advisor

Office of Community Services Email: kate.thomas@acf.hhs.gov Phone: (202)690-5737

RELATED REFERENCES: The Low Income Home Energy Assistance Act, as amended (42 U.S.C. § 8621 et seq .) and LIHEAP-IM-2026-01 Federal Poverty Guidelines and State Median Income Estimates for Optional Use in FY26 and Mandatory Use in FY27

Please contact Help@GrantSolutions.gov for an OLDC account. Please contact the LIHEAP Office immediately if you have questions about the FY27 Model Plan submission process.

Thank you for your attention to these matters. OCS looks forward to continuing to provide high-quality services to OCS partners.

/s/

Corine Frank Director

Office of Community Services

PDF Att 1 LIHEAP AT Model Plan FY27 Cloning Instructions (293.01 KB)

PDF COMM AT LIHEAP Model Plan FY27 (427.57 KB)

PDF Att 2 LIHEAP AT Model Plan FY27 Att 2 Reference Guide (1,652.36 KB)

PDF Att 3 LIHEAP Model Plan Template (Not 508 Compliant) (2,836.41 KB)

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Low Income Home Energy Assistance Program Action Transmittal AT#: LIHEAP-AT-2026-4 DATE: June 10, 2026 TO: All LIHEAP Grant Recipients SUBJECT: Model Plan Application for LIHEAP Funding for Federal Fiscal Year 2027 (FY27) (Application deadline Tuesday, September 1, 2026) ATTACHMENT(S): 1. How to Use the Clone Report Feature in OLDC to Submit a New FY27 LIHEAP Plan. 2. LIHEAP Model Plan Reference Guide. 3. FY27 Model Plan Form

PURPOSE: To provide Low Income Home Energy Assistance (LIHEAP) grant recipients with instructions for how to apply online for federal Fiscal Year 2027 (FY27) LIHEAP funding, confirm the September 1, 2026, LIHEAP Model Plan submission deadline, and remind grant recipients they can “clone” or pre-populate their prior data into a new Plan submission to reduce administrative reporting burden.

BACKGROUND: States, the District of Columbia, territories, and tribes or tribal organizations that wish to administer LIHEAP must submit an application for funds by September 1st (or the date issued by the Office of Community Services (OCS)) each FY, covering a grant period of October 1 through September 30. Section 2605(c)(3) of the federal LIHEAP statute (42 U.S.C. § 8624(c)(1)) provides that the Secretary shall make available a model LIHEAP Plan, which may be used to prepare the application required under sections 2605(a)(1) and (c)(1) (42 U.S.C. § 8624(a)(1) and (c)(1)).

OCS has the responsibility to review and accept LIHEAP Model Plan submissions on behalf of the U.S. Department of Health and Human Services’ (HHS) Administration for Children and Families (ACF). The Office of Management and Budget approved ACF’s LIHEAP Model Plan form under clearance number 0970-0075 is effective through February 28, 2027.

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KEY MODEL PLAN SUBMISSION INFORMATION: Plan Submission Deadline: The deadline for the FY27 Plan is Tuesday, September 1, 2026. Grant recipients must submit the LIHEAP Model Plan via the Online Data Collection (OLDC), located within GrantSolutions, each FY in order to receive LIHEAP funding allocation. For FY27, LIHEAP grant recipients can “clone” or pre-populate their FY26 data into a new Plan, but they must follow the application process outlined below. Transferring Prior-Year Information into a New Plan (OLDC “Clone” Feature): All grant recipients must complete the entire LIHEAP Model Plan for FY27 in OLDC. Grant recipients can transfer information from the FY26 LIHEAP Plan (prior plan) into the new Plan by using the “Clone Report” feature in OLDC. Attachment 1 provides step-by-step instructions for how to use the “Clone Report” feature. After transferring prior year information into the new Plan, at a minimum, grant recipients must update responses to the following sections: SF-424 Mandatory Grant Application section — Fields 1.d., 7.d. (this section will be used as the official point of contact for the public director of State and Territory Grant Recipient Contacts and Tribal Grant Recipient Contacts), 13.a., and 13b. Funding Period, and fields 16 and 17 Authorized Official through the attached Letter of Delegation; Section 1-Program Components, 2605(b)(1)-Question 1.1 Dates of Operations Question 1.2 Estimated Funding Allocations; Section 2—Heating Assistance, 2605(b)(2) — Question 2.1 Eligibility Threshold; Section 3—Cooling Assistance, 2605(b)(2) — Question 3.1 Eligibility Threshold; Section 4 — Crisis Assistance, 2605(c) — Question 4.1 Eligibility Threshold; Section 5—Weatherization Assistance, 2605(b)(2) — Question 5.1 Eligibility Threshold; Section 8 — Agency Designation, 2605(b)(6)-Assurance 6 — Question 8.8. This section is required for state grant recipients and the Commonwealth of Puerto Rico only; Section 10 — Program, Fiscal Monitoring, and Audit, 2605(b)(10)-Assurance 10 — Questions 10.3, 10.9;

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Section 11 — Timely and Meaningful Public Participation, 2605(b)(12), 2605(c)(2) — Questions 11.1-11.5; Section 12 — Fair Hearings, 2605(b)(10) — Questions 12.1-12.3; Section 13 — Reduction of home energy needs, 2605(b)(16) — Questions 13.1-13.5; and Section 16 — Performance Goals and Measures, 2605(b). This section is required of state grant recipients only and optional for other grant recipients. Attach supporting documentation or provide links to supporting documents online, as needed, such as policies and procedures.

Leveraging Activities: The LIHEAP Model Plan includes an optional section (Section 14) to explain possible leveraging activities the grant recipient may take during FY27. Completing this section is one requirement to receive a separate leveraging grant, if funding becomes available. However, OCS awards leveraging grants in the federal FY following the year the grant recipient conducted the leveraging activities. Therefore, if funding becomes available in FY27 for leveraging, OCS would award leveraging grants in FY27 based upon a separate leveraging report that would be reconciled against the responses in the FY26 LIHEAP Model Plan for leveraging activities that took place in FY26. Similarly, if leveraging funding becomes available in FY28, OCS would award leveraging grants in FY28 based upon FY27 LIHEAP Model Plan. OCS last awarded leveraging grants in FY12 and has no estimate for when federal leveraging grants may become available again. However, grant recipients are encouraged to complete this section if they intend to leverage non-federal funds to assist LIHEAP bill payment or weatherization assistance households so that the public and all interested parties can review and comment on the grant recipient’s efforts. Household Report: The statute requires that complete LIHEAP Plans MUST include the LIHEAP Household Report for the previous federal fiscal year regarding assisted households and households applying for assistance. Therefore, in order for the FY27 LIHEAP Plan to be accepted, the FY26 Household Report must be submitted along with the LIHEAP Plan in OLDC. The LIHEAP statute requires the Secretary to collect data on the number and income levels of households assisted and the following additional household data: • Number of assisted households with at least one young child; • Number and income levels of households applying for LIHEAP assistance; and • Number of assisted households with at least one or more individuals who are 60 years or older or disabled.

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States, the District of Columbia, and territories with regular allotments of $200,000 or more must collect this data on their applicant and recipient households in order to submit the data on the Household Report (Long Form — ACF 121). All tribal grantees, and territories with regular allotments of less than $200,000, are required to submit only information on the number of households served in each of its program components (i.e., heating, cooling, crisis, and weatherization on the Household Report Short Form, ACF - 120). The FY 2026 Household Report must be submitted no later than September 1, 2026, with at least estimates provided. If only estimates are provided, or changes to final numbers occur, the FY 2026 Household Report must be resubmitted no later than December 31, 2026, with final data. All grantees must submit the Household Report through OLDC. Quarterly Report (Replacing Carryover Report): Section III: Estimated Use of Funds in the required Quarter 3 report includes the information from the previously required Carryover and Reallotment Report (CRR). This means: the LIHEAP CRR will no longer be a required report in its previous format. The required data will be captured in the LIHEAP Quarterly Report. Two key data elements from the CRR are required explicitly by the federal LIHEAP statute. The data elements include Q3 estimates of how much the grant recipient requests HHS set aside to be carried over from the current federal fiscal year into the next federal fiscal year. The data elements include estimates of how much the grant recipient anticipates having to return to HHS as unobligated and available for HHS to reallot in the next federal fiscal year, as well as includes a required “remarks” field for grant recipients to explain why they are requesting to carryover funds and how they intend to use them in the next year, as required by the LIHEAP statute. Section III of Q4 report asks for the final carryover and reallotment amounts for that year and remarks. The LIHEAP statute (42 U.S.C. § 8626) requires grant recipients to submit information necessary for administration of carryover and reallotment. Pursuant to this authority, HHS conditions the release of grant awards upon submission of the Carryover and Reallotment information provided through the Quarterly Report. Assurances and Certifications: The assurances displayed in the Section 21 of the LIHEAP Model Plan are from the federal LIHEAP statute (42 U.S.C. § 8624(b)(1)-(16)). LIHEAP regulations at 45 CFR § 96.10(b) require that the 16 assurances (15 for tribes) in the LIHEAP statute be certified by the grant recipient’s Chief Executive Officer or “by an individual authorized to make such certifications on behalf of the Chief Executive Officer.” For the LIHEAP Model Plan to be accepted, please be sure that the governor or tribal chairperson (1) certifies the assurances or (2) has specifically delegated authority to “certify” the LIHEAP Assurances to another person or position (not merely the department or agency). The grant recipient must attach a delegation letter to the LIHEAP Model

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Plan in OLDC, and the letter must explicitly specify that the individual is authorized to certify the federal LIHEAP assurances. In addition to the LIHEAP Model Plan, grant recipients must also complete or update the Mandatory Grant Application SF-424, which is the first section of the LIHEAP Model Plan in OLDC. The person that is designated to “certify to the LIHEAP assurances” must have an OLDC account and, while logged into their OLDC account, must be the person that clicks the “Certify” and “Click to Sign” buttons for the LIHEAP Model Plan in OLDC. Therefore, if the governor or tribal chairperson chooses not to designate someone else to sign the LIHEAP assurances, then the governor or tribal chairperson must have their own account and “certify” the FY27 LIHEAP Model Plan in OLDC. States, the District of Columbia, and territories receiving more than $200,000 must describe in their new FY27 Plan how they will carry out assurance 15 (section 2605(b)(15)) of the LIHEAP Act, see 42 U.S.C. § 8624(b)(15)). Assurance 15 requires such grant recipients to offer LIHEAP intake services in addition to those available through agencies also administering the Temporary Assistance for Needy Families (TANF) program. An attachment detailing this plan may be added or entered in any of the fields in Sections 8.2, 8.3, and 8.4. Other Certifications: 1. Section 18 — All LIHEAP grant recipients must agree to the Certification Regarding Debarment, Suspension, and Other Responsibility Matters. 2. Section 19 — All LIHEAP grant recipients must submit the Certification Regarding Drug-Free Workplace Requirements unless a state has submitted a statewide assurance to the U.S. Department of Health and Human Services. When completing this certification, be sure to enter the grant recipient’s physical address in the appropriate fields. No post office (P.O.) boxes allowed. 3. Section 20 —All states must file the Certification Regarding Lobbying certifying they will not use federal funds for lobbying. And, if applicable, complete Form LLL, which discloses lobbying payments if they use non-federal funds to lobby in connection with the award. Tribes and tribal organizations with awards less than $100,000 are not required to complete the Certification Regarding Lobbying. 4. Assurances—All LIHEAP grant recipients must agree to the assurances at 42 U.S.C. § 8624(b)(1)-(16), unless otherwise exempted by law.

The LIHEAP Plan form in OLDC, Sections 18-21, incorporates all the above certifications. Please ensure that the certification checkbox is marked in the required certification section. Meaningful and Timely Public Participation: • States and Territories: The federal law requires states and territories to conduct public hearings on the proposed use and distribution of funds as outlined in the

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FY27 LIHEAP Plan (42 U.S.C. § 8624(a)(2)). Grant recipients should follow their own state and territorial procedures for public hearings. • Tribes: No hearing is required of tribal grant recipients. However, tribal grant recipients are required to obtain timely and meaningful public participation or input from their communities regarding their draft or proposed FY27 LIHEAP Plan (42 U.S.C. § 8624(b)(12)). This may include some combination of web postings, public service announcements, comments by email or phone, stakeholder calls, surveys, etc. Tribes must follow their tribal-wide rules for public participation that they would use with their own tribal funding. Note: Timely means that the public participation process must be completed in advance of and prior to the submission of the Plan to get public comments and allow enough time for internal review.

Required Plan Attachments: The following documents must be attached to the application in OLDC to be considered complete: • Delegation Letter (required if someone other than the Chief Executive, e.g., a governor or tribal chairperson certified the FY Plan in OLDC). • Benefit matrix or matrices showing at least three varying measures (income, household size, and home energy costs or needs) to determine benefit types and amounts of assistance, such as heating, cooling, and crisis assistance. Use the applicable new income guidelines published here. See 42 U.S.C. § 8624(b)(5) for the benefit assurance and 42 U.S.C. § 8622(4) for the definition of “highest home energy needs”) • Minutes, notes, or transcripts of public hearing(s) (states and territories only). • Evidence of Public Participation for Tribes (Tribes). • Optional: Policy Manual, Subrecipient Contract.

For Tribal Applicants: OCS encourages directly funded tribes that receive smaller annual LIHEAP grants to consider joining an existing consortium in their state(s) or forming a consortium with neighboring tribes to reduce the administrative burden of the LIHEAP Plan submission and the required reports. For information on how to form or join a consortium, inquire with your federal LIHEAP Office. This information is available under Section B of the LIHEAP Grantee Resource Guide (formerly known as the Tribal Manual). Submission Deadline Extension: If a grant recipient anticipates needing an extension beyond the September 1, 2026, Plan submission deadline, the grant recipient must submit a letter requesting a deadline extension. The letter must be uploaded as an attachment to an “initialized” FY27 Plan in OLDC. The request must provide a specific, reasonable alternative date

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and a brief explanation of the reason for needing an extension. Tribal grant recipients must obtain written agreement of the extension date from the state(s) in which the tribe’s service areas are located. The state’s concurrence must also be included as an attachment to the initialized 2027 Plan. Extension requests must be submitted prior to Tuesday, September 1, 2026. Follow-up Action on Plan Submissions: Upon receipt of FY27 Plans, OCS staff will review the Plans and either reject the Plan back to the grant recipient via OLDC or accept the plan in OLDC. Grant recipients whose plans are “accepted” in OLDC have no further action to take on the Plan. Grant recipients whose plans are “rejected” in OLDC must take immediate action to edit their Plans according to the comments in the OLDC review sections of the Plan and resubmit the edited Plan to OCS within the deadline indicated in the Plan review remarks in OLDC. The federal LIHEAP regulations require that this editing process must be completed no later than December 15, 2026. This deadline is only regarding edits and attachments that are necessary to resolve missing or inadequate information in the original Plan submission. OCS will only issue FY27 LIHEAP funding upon an appropriation from Congress; apportionment from the Office of Management and Budget (OMB); and the receipt and acceptance of a LIHEAP Plan submission that meets statutorily required information. All LIHEAP grant recipients have an ongoing responsibility throughout the grant period to submit revised Plans and reports, as needed, to reflect changes to ensure HHS ACF OCS has final, actual program data. INQUIRIES: For questions regarding this Model Plan guidance, please contact: Kate Thomas Senior Advisor Office of Community Services Email: kate.thomas@acf.hhs.gov Phone: (202)690-5737

RELATED REFERENCES: The Low Income Home Energy Assistance Act, as amended (42 U.S.C. § 8621 et seq.) and LIHEAP-IM-2026-01 Federal Poverty Guidelines and State Median Income Estimates for Optional Use in FY26 and Mandatory Use in FY27 Please contact Help@GrantSolutions.gov for an OLDC account. Please contact the LIHEAP Office immediately if you have questions about the FY27 Model Plan submission process. Thank you for your attention to these matters. OCS looks forward to continuing to provide high- quality services to OCS partners.

/s/ Corine Frank Director Office of Community Services

Attachment 2 100 Percent, 110 Percent and 150 Percent of the Federal Poverty Guidelines (FPG) for 50 states and the District of Columbia Published on January 15, 2026, by the U.S. Department of Health and Human Services The tables below show the calculations for the FPG for optional use in federal Fiscal Year 2026 (FY26) LIHEAP and mandatory use in FY27 LIHEAP. Select Percentages of FPG for All States except Alaska and Hawaii and for the District of Columbia: Size of Household 100 Percent of FPG 110 Percent of FPG 150 Percent of FPG 1 $15,960 $17,556 $23,940 2 $21,640 $23,804 $32,460 3 $27,320 $30,052 $40,980 4 $33,000 $36,300 $49,500 5 $38,680 $42,548 $58,020 6 $44,360 $48,796 $66,540 7 $50,040 $55,044 $75,060 8 $55,720 $61,292 $83,580 9 $61,400 $67,540 $92,100 10 $67,080 $73,788 $100,620 11 $72,760 $80,036 $109,140 12 $78,440 $86,284 $117,660 For households in the District of Columbia or in any state except Alaska and Hawaii at 100 percent of FPG with more than 12 members, add $5,680 for each additional member. For households at 110 percent of FPG with more than 12 members, add $6,248 for each additional member. For households at 150 percent of FPG with more than 12 members, add $8,520 for each additional member. Select Percentages of FPG for Alaska Size of Household 100 Percent of FPG 110 Percent of FPG 150 Percent of FPG 1 $19,950 $21,945 $29,925

Size of Household 100 Percent of FPG 110 Percent of FPG 150 Percent of FPG 2 $27,050 $29,755 $40,575 3 $34,150 $37,565 $51,225 4 $41,250 $45,375 $61,875 5 $48,350 $53,185 $72,525 6 $55,450 $60,995 $83,175 7 $62,550 $68,805 $93,825 8 $69,650 $76,615 $104,475 9 $76,750 $84,425 $115,125 10 $83,850 $92,235 $125,775 11 $90,950 $100,045 $136,425 12 $98,050 $107,855 $147,075 For households in Alaska at 100 percent of FPG with more than 12 members, add $7,100 for each additional member. For households at 110 percent of FPG with more than 12 members, add $7,810 for each additional member. For households at 150 percent of FPG with more than 12 members, add $10,650 for each additional member. Select Percentages of FPG for Hawaii Size of Household 100 Percent of FPG 110 Percent of FPG 150 Percent of FPG 1 $18,360 $20,196 $27,540 2 $24,890 $27,379 $37,335 3 $31,420 $34,562 $47,130 4 $37,950 $41,745 $56,925 5 $44,480 $48,928 $66,720 6 $51,010 $56,111 $76,515 7 $57,540 $63,294 $86,310 8 $64,070 $70,477 $96,105 9 $70,600 $77,660 $105,900 10 $77,130 $84,843 $115,695

Size of Household 100 Percent of FPG 110 Percent of FPG 150 Percent of FPG 11 $83,660 $92,026 $125,490 12 $90,190 $99,209 $135,285 For households in Hawaii at 100 percent of FPG with more than 12 members, add $6,530 for each additional member. For such households at 110 percent of FPG with more than 12 members, add $7,183 for each additional member. For such households at 150 percent of FPG with more than 12 members, add $9,795 for each additional member.

Attachment 4 State Median Income (SMI) by Household Size for Optional Use in FY26 and Mandatory Use in LIHEAP for FY27 — Households of Size 1 through 61 Geographic Level2 SMI for 4- Person Family3 60% SMI for 1-Person Household 60% SMI for 2- Person Household 60% SMI for 3- Person Household 60% SMI for 4- Person Household 60% SMI for 5- Person Household 60% SMI for 6- Person Household Alabama $102,377 $31,941 $41,769 $51,597 $61,426 $71,254 $81,082 Alaska $139,246 $43,444 $56,811 $70,179 $83,547 $96,914 $110,282 Arizona $112,946 $35,238 $46,081 $56,924 $67,767 $78,609 $89,452 Arkansas $94,627 $29,523 $38,607 $47,691 $56,776 $65,860 $74,944 California $133,021 $41,502 $54,272 $67,042 $79,812 $92,581 $105,351 Colorado $145,177 $45,295 $59,232 $73,169 $87,106 $101,042 $114,979 Connecticut $156,135 $48,714 $63,703 $78,692 $93,681 $108,669 $123,658 Delaware $129,424 $40,380 $52,804 $65,229 $77,654 $90,078 $102,503 District of Columbia $202,000 $63,024 $82,416 $101,808 $121,200 $140,592 $159,984 Florida $108,122 $33,733 $44,113 $54,493 $64,873 $75,252 $85,632 Georgia $115,118 $35,916 $46,967 $58,018 $69,070 $80,121 $91,172 Hawaii $138,463 $43,200 $56,492 $69,784 $83,077 $96,369 $109,661 Idaho $109,072 $34,030 $44,501 $54,972 $65,443 $75,913 $86,384 Illinois $132,343 $41,290 $53,995 $66,700 $79,405 $92,109 $104,814 Indiana $111,012 $34,635 $45,292 $55,949 $66,607 $77,264 $87,921 Iowa $122,269 $38,147 $49,885 $61,623 $73,361 $85,098 $96,836 Kansas $117,736 $36,733 $48,035 $59,338 $70,641 $81,943 $93,246

Geographic Level2 SMI for 4- Person Family3 60% SMI for 1-Person Household 60% SMI for 2- Person Household 60% SMI for 3- Person Household 60% SMI for 4- Person Household 60% SMI for 5- Person Household 60% SMI for 6- Person Household Kentucky $104,132 $32,489 $42,485 $52,482 $62,479 $72,475 $82,472 Louisiana $100,636 $31,398 $41,059 $50,720 $60,381 $70,041 $79,702 Maine $122,022 $38,070 $49,784 $61,498 $73,213 $84,927 $96,641 Maryland $158,187 $49,354 $64,540 $79,726 $94,912 $110,097 $125,283 Massachusetts $171,749 $53,585 $70,073 $86,561 $103,049 $119,536 $136,024 Michigan $119,786 $37,372 $48,872 $60,371 $71,871 $83,370 $94,869 Minnesota $147,939 $46,156 $60,358 $74,560 $88,763 $102,965 $117,167 Mississippi $90,025 $28,087 $36,730 $45,372 $54,015 $62,657 $71,299 Missouri $113,137 $35,298 $46,159 $57,020 $67,882 $78,743 $89,604 Montana $115,773 $36,120 $47,234 $58,348 $69,463 $80,577 $91,691 Nebraska $121,844 $38,015 $49,712 $61,409 $73,106 $84,802 $96,499 Nevada $105,027 $32,768 $42,850 $52,933 $63,016 $73,098 $83,181 New Hampshire $156,134 $48,713 $63,702 $78,691 $93,680 $108,668 $123,657 New Jersey $164,337 $51,273 $67,049 $82,825 $98,602 $114,378 $130,154 New Mexico $92,482 $28,854 $37,732 $46,610 $55,489 $64,367 $73,245 New York $137,050 $42,759 $55,916 $69,073 $82,230 $95,386 $108,543 North Carolina $113,006 $35,257 $46,106 $56,954 $67,803 $78,651 $89,499 North Dakota $132,554 $41,356 $54,081 $66,806 $79,532 $92,257 $104,982 Ohio $117,810 $36,756 $48,066 $59,376 $70,686 $81,995 $93,305 Oklahoma $96,528 $30,116 $39,382 $48,649 $57,916 $67,182 $76,449 Oregon $129,250 $40,326 $52,734 $65,142 $77,550 $89,958 $102,366

Geographic Level2 SMI for 4- Person Family3 60% SMI for 1-Person Household 60% SMI for 2- Person Household 60% SMI for 3- Person Household 60% SMI for 4- Person Household 60% SMI for 5- Person Household 60% SMI for 6- Person Household Pennsylvania $129,682 $40,460 $52,910 $65,359 $77,809 $90,258 $102,707 Rhode Island $139,136 $43,410 $56,767 $70,124 $83,481 $96,837 $110,194 South Carolina $106,470 $33,218 $43,439 $53,660 $63,882 $74,103 $84,324 South Dakota $118,003 $36,816 $48,144 $59,472 $70,801 $82,129 $93,457 Tennessee $105,327 $32,861 $42,973 $53,084 $63,196 $73,307 $83,418 Texas $112,239 $35,018 $45,793 $56,568 $67,343 $78,117 $88,892 Utah $122,407 $38,190 $49,941 $61,692 $73,444 $85,195 $96,946 Vermont $135,326 $42,221 $55,212 $68,203 $81,195 $94,186 $107,177 Virginia $143,516 $44,776 $58,554 $72,331 $86,109 $99,886 $113,663 Washington $146,816 $45,806 $59,900 $73,994 $88,089 $102,183 $116,277 West Virginia $98,088 $30,603 $40,019 $49,435 $58,852 $68,268 $77,684 Wisconsin $127,769 $39,863 $52,129 $64,395 $76,661 $88,926 $101,192 Wyoming $114,932 $35,858 $46,892 $57,925 $68,959 $79,992 $91,025 Puerto Rico $44,703 $13,946 $18,238 $22,529 $26,821 $31,112 $35,403 1 Prepared by the Administration for Children and Families, Office of Community Services, Division of Energy Assistance. In accordance with 45 CFR 96.85, 60 percent of each state's estimated median income for a four-person family is multiplied by the following percentages to adjust for household size for LIHEAP: 52 percent for one person, 68 percent for two persons, 84 percent for three persons, 100 percent for four persons, 116 percent for five persons, and 132 percent for six persons. For each additional household member above six persons, add three percentage points to the percentage for a six-person household (132 percent) and multiply the new percentage by 60 percent of the state's estimated median income for a four-person household. 2 The estimated U.S. median income for 4-person families is $123,422 for the period of October 1, 2026, through September 30, 2027. 3 Prepared by the U.S. Census Bureau, U.S. Department of Commerce (Census Bureau) from the 2020 through 2024 American Community Surveys (ACS). For further information, see table B19119 for the five-year estimates of the 2020 ACS through 2024 ACS at data.census.gov or contact the Census Bureau at census.data@census.gov or at 1-800-923-8282.

State Median Income (SMI) by Household Size for Optional Use in FY26 and Mandatory Use in LIHEAP for FY27—Households of Size 7 through 124 Geographic Level5 SMI for 4- person family6 60% SMI for 7- Person Household 60% SMI for 8- Person Household 60% SMI for 9- Person Household 60% SMI for 10-Person Household 60% SMI for 11-Person Household 60% SMI for 12-Person Household Alabama $102,377 $82,925 $84,767 $86,610 $88,453 $90,296 $92,139 Alaska $139,246 $112,788 $115,294 $117,801 $120,307 $122,814 $125,320 Arizona $112,946 $91,485 $93,518 $95,551 $97,584 $99,617 $101,650 Arkansas $94,627 $76,647 $78,350 $80,054 $81,757 $83,460 $85,164 California $133,021 $107,746 $110,140 $112,534 $114,929 $117,323 $119,718 Colorado $145,177 $117,593 $120,206 $122,819 $125,432 $128,045 $130,659 Connecticut $156,135 $126,469 $129,279 $132,090 $134,900 $137,711 $140,521 Delaware $129,424 $104,832 $107,162 $109,492 $111,821 $114,151 $116,481 District of Columbia $202,000 $163,620 $167,256 $170,892 $174,528 $178,164 $181,800 Florida $108,122 $87,578 $89,524 $91,470 $93,417 $95,363 $97,309 Georgia $115,118 $93,244 $95,316 $97,388 $99,460 $101,532 $103,605 Hawaii $138,463 $112,153 $114,646 $117,138 $119,630 $122,123 $124,615 Idaho $109,072 $88,348 $90,311 $92,274 $94,237 $96,201 $98,164 Illinois $132,343 $107,196 $109,578 $111,961 $114,343 $116,725 $119,107 Indiana $111,012 $89,919 $91,917 $93,915 $95,914 $97,912 $99,910 Iowa $122,269 $99,037 $101,238 $103,439 $105,639 $107,840 $110,041 Kansas $117,736 $95,365 $97,484 $99,603 $101,723 $103,842 $105,961 Kentucky $104,132 $84,346 $86,221 $88,095 $89,969 $91,844 $93,718

Geographic Level5 SMI for 4- person family6 60% SMI for 7- Person Household 60% SMI for 8- Person Household 60% SMI for 9- Person Household 60% SMI for 10-Person Household 60% SMI for 11-Person Household 60% SMI for 12-Person Household Louisiana $100,636 $81,514 $83,325 $85,137 $86,948 $88,760 $90,571 Maine $122,022 $98,837 $101,033 $103,230 $105,426 $107,623 $109,819 Maryland $158,187 $128,131 $130,978 $133,825 $136,673 $139,520 $142,368 Massachusetts $171,749 $139,116 $142,207 $145,299 $148,390 $151,482 $154,573 Michigan $119,786 $97,025 $99,181 $101,338 $103,494 $105,650 $107,806 Minnesota $147,939 $119,830 $122,492 $125,155 $127,818 $130,481 $133,144 Mississippi $90,025 $72,920 $74,540 $76,161 $77,781 $79,402 $81,022 Missouri $113,137 $91,640 $93,677 $95,713 $97,750 $99,786 $101,823 Montana $115,773 $93,775 $95,858 $97,942 $100,026 $102,110 $104,194 Nebraska $121,844 $98,693 $100,886 $103,079 $105,272 $107,465 $109,659 Nevada $105,027 $85,071 $86,962 $88,852 $90,743 $92,633 $94,524 New Hampshire $156,134 $126,468 $129,278 $132,088 $134,899 $137,709 $140,520 New Jersey $164,337 $133,112 $136,070 $139,028 $141,986 $144,944 $147,903 New Mexico $92,482 $74,910 $76,574 $78,239 $79,904 $81,568 $83,233 New York $137,050 $111,010 $113,477 $115,944 $118,411 $120,878 $123,345 North Carolina $113,006 $91,534 $93,568 $95,602 $97,636 $99,670 $101,704 North Dakota $132,554 $107,368 $109,754 $112,140 $114,526 $116,912 $119,298 Ohio $117,810 $95,426 $97,546 $99,667 $101,787 $103,908 $106,029 Oklahoma $96,528 $78,186 $79,924 $81,661 $83,399 $85,136 $86,874 Oregon $129,250 $104,692 $107,019 $109,345 $111,672 $113,998 $116,325 Pennsylvania $129,682 $105,042 $107,376 $109,710 $112,044 $114,379 $116,713

Geographic Level5 SMI for 4- person family6 60% SMI for 7- Person Household 60% SMI for 8- Person Household 60% SMI for 9- Person Household 60% SMI for 10-Person Household 60% SMI for 11-Person Household 60% SMI for 12-Person Household Rhode Island $139,136 $112,699 $115,203 $117,708 $120,212 $122,717 $125,221 South Carolina $106,470 $86,240 $88,157 $90,073 $91,990 $93,906 $95,823 South Dakota $118,003 $95,581 $97,705 $99,829 $101,953 $104,077 $106,201 Tennessee $105,327 $85,314 $87,210 $89,106 $91,002 $92,898 $94,794 Texas $112,239 $90,913 $92,933 $94,953 $96,973 $98,994 $101,014 Utah $122,407 $99,149 $101,352 $103,556 $105,759 $107,962 $110,166 Vermont $135,326 $109,613 $112,049 $114,484 $116,920 $119,356 $121,792 Virginia $143,516 $116,247 $118,830 $121,413 $123,996 $126,580 $129,163 Washington $146,816 $118,920 $121,562 $124,205 $126,848 $129,490 $132,133 West Virginia $98,088 $79,450 $81,215 $82,981 $84,746 $86,512 $88,278 Wisconsin $127,769 $103,492 $105,792 $108,092 $110,391 $112,691 $114,991 Wyoming $114,932 $93,094 $95,163 $97,232 $99,300 $101,369 $103,438 Puerto Rico $44,703 $36,208 $37,012 $37,817 $38,622 $39,426 $40,231 DEA/SM 2/9/2026 4 Prepared by the Administration for Children and Families, Office of Community Services, Division of Energy Assistance. In accordance with 45 CFR 96.85, 60 percent of each state's estimated median income for a four-person family is multiplied by the following percentages to adjust for household size for LIHEAP: 135 percent for seven persons, 138 percent for eight persons, 141 percent for nine persons, 144 percent for 10 persons, 147 percent for 11 persons, and 150 percent for 12 persons. For each additional household member above 12 persons, add three percentage points to the percentage for a 12-person household (150 percent) and multiply the new percentage by 60 percent of the state's estimated median income for a four-person household. 5 The estimated U.S. median income for 4-person families is $123,422 for the period of October 1, 2026, through September 30, 2027. 6 Prepared by the U.S. Census Bureau, U.S. Department of Commerce (Census Bureau) from the 2020 through 2024 American Community Surveys (ACS). For further information, see table B19119 for the five-year estimates of the 2020 ACS through 2024 ACS at data.census.gov or contact the Census Bureau at census.data@census.gov or at 1-800-923-8282.

P. 1/4 Low Income Home Energy Assistance Program Information Memorandum AT#: LIHEAP-IM-2026-01 DATE: April 24, 2026 TO: Low Income Home Energy Assistance Program (LIHEAP) Grant Recipients SUBJECT: Federal Poverty Guidelines (FPG) and State Median Income (SMI) Estimates for LIHEAP Income Eligibility Optional Use in federal Fiscal Year 2026 (FY26) and Mandatory Use in FY27 ATTACHMENT(S): (1) Federal Register Vol. 91, No. 10/Thursday, January 15, 2026/Notice Department of Health and Human Services Annual Update of the HHS Poverty Guidelines (91 FR 1797) Published on January 15, 2026 by the U.S. Department of Health and Human Services (2) 100 percent, 110 percent, and 150 percent of the Federal Poverty Guidelines for 50 states and the District of Columbia, Published on January 15, 2026 by the U.S. Department of Health and Human Services (PDF) (3) 100 percent, 110 percent, and 150 percent of the Federal Poverty Guidelines adjusted for LIHEAP Use by Puerto Rico (PDF) (4) State Median Income (SMI) by Household Size for Mandatory Use in FY27 (PDF) RELATED REFERENCES: (1) The Low Income Home Energy Assistance Act, Title XXVI of the Omnibus Budget Reconciliation Act of 1981, Public Law 97-35, as amended; (2) 45 CFR 96.85(a)(b), Income Eligibility - Final Rule, published in the Federal Register on March 3, 1988 (53 FR 6827) and amended October 15, 1999 (64 FR 55858); and (3) Annual Update of the HHS Poverty Guidelines, Federal Register notice dated Thursday, January 15, 2026 (91 FR 1797). PURPOSE

P. 2/4 To provide Low Income Home Energy Assistance Program (LIHEAP)-specific updates to the federal poverty guidelines (FPG), which the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE) issued on January 15, 2026. LIHEAP grant recipients that base their income eligibility criteria on FPG may use these guidelines for their federal Fiscal Year 2026 (FY26) programs and must use these guidelines for their FY27 programs. To provide LIHEAP-specific adjustments to the FPG for recommended use by the Commonwealth of Puerto Rico and the other U.S. territories that provide LIHEAP assistance in FY26 and FY27 (Attachment 3 (PDF)). To provide LIHEAP grant recipients the state median income (SMI) estimates for optional use as of the date of this publication in LIHEAP for FY26 and mandatory use in FY27 (Attachment 4 (PDF)). BACKGROUND Section 2605(b)(2)(B) of Public Law 97-35, 42 U.S.C. § 8624(b)(2)(B) establishes the following requirements that LIHEAP grant recipients must follow in setting the income eligibility criteria of their programs: (1) Grant recipients may make eligible solely on the basis of household income which does not exceed the greater of. — (A) an amount equal to 150 percent of FPG for the state; or (B) an amount equal to 60 percent of the SMI for the state; and (2) Grant recipients may not exclude from eligibility solely on the basis of household income which falls below 110 percent of FPG for such state — though grant recipients may give priority to those households with the highest home energy costs or needs in relation to household income. CONTENT ASPE updated the FPG in Attachment 1 (PDF), which presents the text of that notice. LIHEAP grant recipients that use FPG to set their income eligibility criteria are to adopt these guidelines in the manner indicated below. This memorandum also updates the OCS LIHEAP income eligibility limits based upon the SMI for the 50 states, the District of Columbia, and the Commonwealth of Puerto Rico. These limits outline the maximum threshold that LIHEAP grant recipients may use in setting their programs’ income eligibility criteria. OCS calculated these limits from the SMI estimates for a four-person family developed by the United States Census Bureau (Census Bureau). HHS calculated 60 percent of the Census

P. 3/4 Bureau’s estimates from the American Community Survey (ACS) to determine the maximum SMI for LIHEAP eligibility. OCS calculated the limits specified at 45 CFR 96.85. This methodology outlines that OCS shall multiply the limit for a four-person household by one of the following: • 52 percent for one person; • 68 percent for two persons; • 84 percent for three persons; • 100 percent for four persons; • 116 percent for five persons; • 132 percent for six persons; • 135 percent for seven persons; • 138 percent for eight persons; • 141 percent for nine persons; • 144 percent for 10 persons; • 147 percent for 11 persons; and • 150 percent for 12 persons. OCS did not calculate the limits for households of sizes greater than 12 persons; however, those limits are based on that for a four-person family times 150 percent plus 3 percentage points for each household member above 12. See Attachment 4 (PDF) for (1) the 60 percent of SMI figures for households of sizes one through 12; and (2) the instructions for calculating 60 percent of SMI for households of sizes greater than 12. When making income eligibility determinations on applications for LIHEAP assistance, grant recipients must determine the SMI-based limits on household size, not family size, as defined by the federal LIHEAP statute at 42 USC 8622(5). Although the figures presented in the attachments show limits by family size, grant recipients should use the applicable limit for a family presented here as the limit for a household in their programs. Household Household is defined in the Section 2603(5) of the LIHEAP statute [42 U.S.C. § 8622(5)] as “any individual or group of individuals who are living together as one economic unit for whom residential energy is customarily purchased in common or who make undesignated payments for energy in the form of rent.” Income The LIHEAP statute does not define income. Generally, income means gross income, but a number of grant recipients choose to use net income to deduct for medical expenses over a certain level, or for some limited expenses associated with employment such as childcare.

P. 4/4 Program Eligibility Criteria Grant recipients have the option, but are not required, to establish additional requirements for income-eligible households to be eligible for LIHEAP. Territorial Calculations HHS does not issue poverty guidelines overall for federal programs in the territories. HHS has indicated that federal programs are generally responsible for deciding whether to use the Continental United States poverty guidelines for the territories or to follow some other procedure (as referenced in 91 FR 1797 (Attachment 1 (PDF)). However, the Office of Community Services (OCS) has developed an approach to annually adjust the poverty guidelines for the Commonwealth of Puerto Rico’s use in determining LIHEAP income eligibility. A similar adjustment is not available for the other territories at this time. OCS recommends that the other territories use the adjusted poverty guidelines provided in Attachment 3 (PDF) in determining LIHEAP income eligibility for FY27. Mandatory Use Grant recipients must adopt these estimates by no later than October 1, 2026 (the beginning of FY27), or the beginning of the grant recipient’s fiscal year, whichever is later. INQUIRIES TO Please send all inquiries to: Sharnice Mitchell, Office of Community Services Administration for Children and Families The U.S. Department of Health and Human Services 330 C Street, S.W. Washington, D.C. 20201 Sharnice.Mitchell1@acf.hhs.gov https://www.acf.hhs.gov/ocs/programs/liheap Thank you for your attention to these matters. OCS looks forward to continuing to provide high- quality services to OCS partners. /s/ J. Janelle George Acting Director Office of Community Services