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LIHEAP - Forms

LIHEAP Forms 

Use of the forms below is outlined in the LIHEAP Policy and Procedures Manual.

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As per Section 22.5 of the LIHEAP Contract, Closeout Reports are due within 45 calendar days of the end of the Contract period.

FY20 LIHEAP Closeout Form (Excel) (uploaded 08/31/20)

This form's use is required for ECIP-only heating system repair ($500 or more) and replacement. This form does NOT have to be completed electronically. The inspector may complete it by hand. There is no need to duplicate efforts by completing by hand and then electronically. 

ECIP Heating Unit Inspection Sheet (PDF) (uploaded 10/04/19)
ECIP Heating Unit Inspection Sheet (Excel) (uploaded 10/04/19)

FY21 Intake Form - Definitions (PDF) (uploaded 08/31/20)

FY21 Intake Form - English (PDF) (uploaded 08/31/20)
FY21 Intake Form - English (Excel) (uploaded 08/31/20)

FY21 Intake Form - Spanish (PDF) (uploaded 08/31/20)
FY21 Intake Form - Spanish (Excel) (uploaded 08/31/20)

Other Languages
FY21 Intake Form - Arabic (Middle Eastern) (PDF) (uploaded 10/06/20)
FY21 Intake Form - Arabic (Middle Eastern) (Word) (uploaded 10/06/20)

FY21 Intake Form - Arabic (South Sudanese) (PDF) (uploaded 10/06/20)
FY21 Intake Form - Arabic (South Sudanese) (Word) (uploaded 10/06/20)

FY21 Intake Form - Burmese (Myanmar) (PDF) (uploaded 10/06/20)
FY21 Intake Form - Burmese (Myanmar) (Word) (uploaded 10/06/20)

FY21 Intake Form - Chin (Hakha) (PDF) (uploaded 10/06/20)
FY21 Intake Form - Chin (Hakha) (Word) (uploaded 10/06/20)

FY21 Intake Form - French (African) (PDF) (uploaded 10/06/20)
FY21 Intake Form - French (African) (Word) (uploaded 10/06/20)

FY21 Intake Form - Karen (PDF) (uploaded 10/06/20)
FY21 Intake Form - Karen (Word) (uploaded 10/06/20)

FY21 Intake Form - Karenni (PDF) (uploaded 10/06/20)
FY21 Intake Form - Karenni (Word) (uploaded 10/06/20)

FY21 Intake Form - Kinyarwanda (PDF) (uploaded 10/06/20)
FY21 Intake Form - Kinyarwanda (Word) (uploaded 10/06/20)

FY21 Intake Form - Kunama (PDF) (uploaded 10/06/20)
FY21 Intake Form - Kunama (Word) (uploaded 10/06/20)

FY21 Intake Form - Marshallese (PDF) (uploaded 10/06/20)
FY21 Intake Form - Marshallese (Word) (uploaded 10/06/20)

FY21 Intake Form - Nepali (PDF) (uploaded 10/06/20)
FY21 Intake Form - Nepali (Word) (uploaded 10/06/20)

FY21 Intake Form - Swahili (PDF) (uploaded 10/06/20)
FY21 Intake Form - Swahili (Word) (uploaded 10/06/20)

FY21 Intake Form - Tagalog (PDF) (uploaded 10/06/20)
FY21 Intake Form - Tagalog (Word) (uploaded 10/06/20)

FY21 Intake Form - Tigrinya (Ethiopia) (PDF) (uploaded 10/06/20)
FY21 Intake Form - Tigrinya (Ethiopia) (Word) (uploaded 10/06/20)

FY21 Intake Form - Vietnamese (PDF) (uploaded 10/06/20)
FY21 Intake Form - Vietnamese (Word) (uploaded 10/06/20)


 

FY21 Monthly Expenditure Report (Excel) (uploaded 08/31/20)

* Due the 10th of each month 

* Instructions - Written (PDF) (uploaded 08/31/20)
* Instructions - Excel Spreadsheet with Notations (PDF) (08/31/20)
 

CARES Act Monthly Expenditure Report (Excel) (uploaded 05/26/20)

* Due the 10th of each month 

DCAA Email Expenditure Report Procedures

Subgrantees of the DCAA electronically submit expense reports for CSBG, LIHEAP, FaDSS, and Weatherization (DOE, HEAP, and Utilities).  The following protocol is required for electronic submission:

  • Subgrantees will prepare and process their Monthly Expenditure Reports according to DCAA requirements and the subgrantee’s established process. 
  • Each report must have an authorized signature.
  • Each report must be sent as a PDF file by separate email. 
  • The subject line and the PDF file for each email must identify the DCAA program, month, and year for each report (e.g., LIHEAP-20-01 January).
  • The subgrantee must maintain an original signed copy of the report submitted in accordance with DCAA contract requirements. Original copies must be available for review at the request of the DCAA. 
  • Reports must be emailed to dcaa@iowa.gov.
  • Subgrantees will receive an automated response from dcaa@iowa.gov acknowledging the receipt of the email. 

Agencies may submit reports electronically or by regular mail. Agencies are not allowed to use one method of submission for some DCAA programs and another method for other DCAA programs, or to use one method one month and another method for a different month. DCAA has been advised by the Department of Administrative Services that agencies must submit invoices to the State in accordance with the agency's "normal business practice", which can be by either method, but not both. If your agency establishes email submission as your normal business practice for submission, all DCAA reports would need to be submitted in that manner. Reports not submitted according to the agency's normal business practice will not be accepted.  

Expenditure Report Guidance for Nifcappers (PDF) (added 12/09/17)

Please note, this guidance can be used to train new staff on completing the expenditures report. This is meant only for new LIHeap Coordinators and does not reflect guidance for filling out portions that fiscal would typically complete.  

Payment to Secondary Vendor Form (PDF) (uploaded 08/31/20)
 

Proxy Form (PDF) (added date fields and uploaded 09/29/20)

Self-Employment Form (PDF) (08/31/20)

Waiver - 14 Days Cash On-Hand (PDF) (uploaded 01/06/19)