California Service and Repair Contract by zyi23843

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									State of California                                                                                                                                                   Page 1 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                             2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                Contract Number: Report Period:  Advance Request:                                                                   1
                                                                                                                                                                Adjustment

Prepared By (Print Name/Title):                              E-mail Address:                                                  Phone Number:            Fax Number:

10 - ASSURANCE 16 COSTS
 1. Assurance 16 Activities                                                                                                                             $
20 - ADMINISTRATIVE COSTS (ASSURANCE 16, ECIP, AND HEAP)
 1 Administrative Costs                                                                                                                                 $
30 - INTAKE COSTS (ECIP AND HEAP)
                  2
  1      Intake                                                                                                                                         $
40 - OUTREACH COSTS (ECIP AND HEAP)
 1. Outreach                                                                                                                                            $
50 - ECIP/HEAP COSTS
 1. ECIP EHCS Cooling Service Repair/Replacement (Total from Section 220)                                                                               $
 2. ECIP EHCS Heating Service Repair/Replacement (Total from Section 225)                                                                               $
 2a. ECIP EHCS Water Heater Repair/Replacement (Total from Section 227)                                                                                 $
  3 ECIP EHCS Other Program Costs (Total from Section 230 and 236)                                                                                      $
  4 ECIP Wood, Propane, and Oil Payments                                                                                                                $
  5 Severe Weather Energy Assistance and Transportation Services (SWEATS) (Total from Section 244)                                                      $
  6 HEAP Wood, Propane, and Oil Payments                                                                                                                $
  7 Liability Insurance                                                                                                                                 $
  8 Training and Technical Assistance                                                                                                                   $
  9 Vehicle and Equipment                                                                                                                               $
 10 Workers' Compensation                                                                                                                               $
      TOTAL ECIP/HEAP Costs                                                                                                                             $
52 - TOTAL COSTS BEFORE REPAYMENT
 1. Total Costs Before Repayment (Total of Sections 10, 20, 30, 40 and 50)                                                                              $
55 - FOR INFORMATIONAL USE ONLY (NOT INCLUDED IN TOTAL COSTS)
 1. Intake - For informational use only 4                                                                                 $
58 - ADVANCE REPAYMENT
 1. Advance Repayment                                                                                                                                   $
60 - TOTAL COSTS
 1. TOTAL Costs                                                                                                                                         $
                                               CONTRACTOR'S CERTIFICATION
  I hereby certify under penalty of perjury that I am the duly appointed, qualified, and acting officer of the herein named Agency, Department, Board, Commission, Office or
  Institution, and that to the best of my knowledge, the actual expenditures and activities made during this reporting period contained within this document are in all respects
  true, correct, and in accordance with the purpose, terms and conditions of the contract referenced above, Federal and State Regulations or other statutes.

Authorized Person (Print Name/Title):                                      Signature:                                                                       Date:

                                                                            4
                                                                   CSD ACCOUNTING USE ONLY
Payment:                               PCA#                                       Approved By:                                                              Date:


      1 Enter reporting period being adjusted. Insert only increase or decrease on each line item being        3 Used only for households receiving emergency assistance.
        revised using + or - sign.                                                                             4 Enter actual additional Intake charged to Administrative Costs.
      2 Intake costs in excess of 2% may be charged to Administrative Costs.
State of California                                                                                                                                                                        Page 2 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)

                                                                   2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                          Contract Number:                           Report Period:                              Adjustment


                                                                           ECIP PROGRAM HOUSEHOLDS AND EHCS
100 - ECIP HCS & WPO PROGRAM HOUSEHOLDS                                               120 - ECIP EHCS ONLY OTHER DWELLING TYPES

 1.   Cooling Service, Repair or Replacement                             1#              1     Total Dwellings Receiving Prior EHCS Service                                            #
 2.   Heating Service, Repair or Replacement                             1#                    Total Dwellings Receiving Assessments and/or Diagnostic Tests But No Other HCS
                                                                                         2                                                                                             #
 2a. Water Heater Service, Repair or Replacement                         1#                    Services

 3.   Wood/Propane/Oil Dwellings                                         2#              3     Total Combo Dwellings Receiving EHCS Services in Current Program Year                   #

110 - ECIP EHCS ONLY SERVICED DWELLINGS BY TYPE                                       125 - ECIP EHCS ONLY LEAD-SAFE WEATHERIZED DWELLINGS

 1.   Single Family Site-Built - Owner Occupied                           #              1     Dwellings Built Before 1979 (Include HUD Dwellings)                                     #

 2.   Single-Family Site-Built - Rental                                   #           130 - ECIP EHCS ONLY HOUSING AND URBAN DEVELOPMENT (HUD) DWELLINGS

 3.   Multi-Unit (two to four units)                                      #              1     HUD Dwellings Serviced                                                                  #

 4.   Multi-Unit (five or more units)                                     #              2     HUD Dwellings Built Before 1979                                                         #

 5.   Mobile Home - Owner-Occupied                                        #              3     HUD Dwellings Requiring Certified Lead-Safe Inspections After Services Provided         #

 6.   Mobile Home - Rental                                                #           135 - ECIP EHCS ONLY REPAIR/REPLACEMENT CRITERIA

                                   Total Serviced Dwellings by Type      1#              1     Dwellings With Non-Operating Heating/Cooling Source                                     #

115 - ECIP EHCS ONLY SERVICED DWELLINGS BY PRIMARY HEATING FUEL                          2     Dwellings With Heating/Cooling Source in Crisis                                         #

  1   Natural Gas                                                         #                                                                      Total Repair/Replacement Criteria   1 #

  2   Fuel Oil                                                            #           140 - ECIP EHCS ONLY PROGRAM LEVERAGING

  3   Electricity                                                         #              1     Dwellings Referred to LIHEAP, DOE or Other Non-CSD Weatherization Programs              #

  4   Propane/LPG                                                         #              2     Dwellings Currently or Previously Weatherized and Not Requiring Referral                #

  5   Kerosene                                                            #              3     Dwellings Not Referred for Weatherization Services                                      #

  6   Wood                                                                #                                                                           Total Program Leveraging       1 #

  7   Other                                                               #

  8   Total Serviced Dwellings by Primary Heating Fuel         1          #

                                                                                             1 The total for ECIP HCS Program Households of line items 1 and 2, Sectikon 100 should match with Sections
                                                                                               110, 115, 140, 145 and 155.

                                                                                             2 ECIP WPO Program Households served should match with Sections 175 & 185
State of California                                                                                                                                                                                        Page 3 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                    2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                 Contract Number:       Report Period:                                                     Adjustment


                                                                                             ECIP - EHCS
145 - ECIP EHCS NUMBER OF HOUSEHOLDS ASSISTED BY GROSS MONTHLY INCOMES                         160 - ECIP EHCS DEMOGRAPHICS - TYPES OF PEOPLE ASSISTED
(Transfer totals from the HHs Tally Sheet by Poverty Levels)                                      1     Elderly (60 Years or older)                                                            #

  1   Under 75%                                                                   #               2     Disabled                                                                               #

  2   75% - 100%                                                                  #               3     Native American Indians                                                                #

  3   101% - 125%                                                                 #               4     Children (Age 0 to 5 Years)                                                            #

  4   126% - 150%                                                                 #               5     Children (Age 6 to 18 Years)                                                           #

  5   Over 150%                                                                   #               6     Seasonal/Migrant Farm Workers                                                          #
                                                                              1                         Limited English-Speaking Persons
  6                    Total Households Assisted With Gross Monthly Incomes       #               7                                                                                            #
150 - ECIP EHCS NUMBER OF HOUSEHOLDS ASSISTED WITH AT LEAST ONE MEMBER                         165 - ECIP EHCS NUMBER OF PEOPLE ASSISTED
WHO IS:                                                                                           1     Total Number of People Assisted (count each person only once)                          #
  1   Elderly (60 Years or Older)                                                 #            170 - ECIP EHCS AVERAGE HOUSEHOLD ENERGY BURDEN

  2   Disabled                                                                    #                     From the Intake applications, calculate the average energy burden percentage of EHCS
                                                                                                  1                                                                                            #
  3   Age 5 Years or Under (This is NOT the total of lines 39 amd 40)             #                     and WPO households assisted during the reporting period.

  4   Age 2 Years and Under                                                       #

  5   Age 3 Years Through 5 Years                                                 #

  6   Dwellings with Seasonal/Migrant Farm Workers                                #

  7   Dwellings with Limited English-Speaking Persons                             #

  8   Dwellings with Native American Indians                                      #
155 - ECIP EHCS NUMBER OF HOUSEHOLDS ASSISTED BY ENERGY BURDEN
(Unduplicated-Include all households served both vulnerable population and non-vulnerable
population)
  1   Range: From 0% to 5.0%                                                      #

  2   Range: From 5.1% to 10%                                                     #

  3   Range: From 10.1% to 15%                                                    #

  4   Range: From 15.1% to 20%                                                    #
  5   Range: From 20.1% to 25%                                                    #                   1 The totals for ECIP EHCS should match in Sections 145, 155, 100 Line Items 1 and 2, 110 and 115.

  6   Range: From 25.1% and higher                                                #
  7                                                  1                            #
      Total Households Assisted by Energy Burden
State of California                                                                                                                                                                                Page 4 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                      2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                 Contract Number:       Report Period:                                                     Adjustment


                                                                                             ECIP - WPO
                                                                                               190 - ECIP WPO DEMOGRAPHICS - TYPES OF PEOPLE ASSISTED
175 - ECIP WPO NUMBER OF HOUSEHOLDS ASSISTED WITH GROSS MONTHLY INCOMES
                                                                                                  1     Elderly (60 Years or older)                                                            #

  1   Under 75%                                                                #                  2     Disabled                                                                               #

  2   75% - 100%                                                               #                  3     Native American Indians                                                                #

  3   101% - 125%                                                              #                  4     Children (Age 0 to 5 Years)                                                            #

  4   126% - 150%                                                              #                  5     Children (Age 6 to 18 Years)                                                           #

  5   Over 150%                                                                #                  6     Seasonal/Migrant Farm Workers                                                          #

  6                                                                        1                      7     Limited English-Speaking Persons                                                       #
                       Total Households Assisted With Gross Monthly Incomes #
180 - ECIP WPO NUMBER OF HOUSEHOLDS ASSISTED WITH AT LEAST ONE MEMBER                          195 - ECIP WPO NUMBER OF PEOPLE ASSISTED
WHO IS:                                                                                           1     Total Number of People Assisted (count each person only once)                          #
  1   Elderly                                                                  #               200 - ECIP WPO AVERAGE HOUSEHOLD ENERGY BURDEN

  2   Disabled                                                                 #                        From the Intake applications, calculate the average energy burden percentage of EHCS
                                                                                                  1                                                                                            #
  3   Age 5 Years or Under (This is NOT the total of lines 4 and 5)                                     and WPO households assisted during the reporting period.
                                                                               #
  4   Age 2 Years and Under                                                    #
  5   Age 3 Years Through 5 Years                                              #
  6   Dwellings with Seasonal/Migrant Farm Workers                             #
  7   Dwellings with Limited English-Speaking Persons                          #
185 - ECIP WPO NUMBER OF HOUSEHOLDS ASSISTED BY ENERGY BURDEN
(Unduplicated-Include all households served both vulnerable population and non-vulnerable
population)
  1   Range: From 0% to 5.0%                                                   #

  2   Range: From 5.1% to 10%                                                  #

  3   Range: From 10.1% to 15%                                                 #

  4   Range: From 15.1% to 20%                                                 #

  5   Range: From 20.1% to 25%                                                 #

  6   Range: From 25.1% and higher                                             #                      1 The totals for ECIP WPO in Sections 175, 185, should match with Section 100 Line 2.

  7                                                   1                        #
      Total Households Assisted by Energy Burden
State of California                                                                                                                                                                                    Page 5 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                    2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                                 Contract Number:                             Report Period:                          Adjustment


                                                                                                 HEAP WPO
205 - HEAP NUMBER OF HOUSEHOLDS ASSISTED WITH GROSS MONTHLY INCOMES (Transfer totals                                                                                                         2
from the Households Tally Sheet by Poverty Levels)                                                             212- HEAP WPO DEMOGRAPHICS - TYPES OF PEOPLE ASSISTED

  1   Under 75%                                                                              #                    1     Elderly (60 Years or older)                                              #

  2   75% - 100%                                                                             #                    2     Disabled                                                                 #
  3   101% - 125%                                                                            #                    3     Native American Indians                                                  #
  4   126% - 150%                                                                            #                    4     Children (Age 0 to 5 Years)                                              #

  5   Over 150%                                                                              #                    5     Children (Age 6 to 18 Years)                                             #
                                                                                         1
  6                             Total Households Assisted With Gross Monthly Incomes         #                    6     Seasonal/Migrant Farm Workers                                            #
                                                                                                                  7     Limited English-Speaking Persons                                         #

210 - HEAP NUMBER OF HOUSEHOLDS ASSISTED WITH AT LEAST ONE MEMBER WHO IS:                            2         213 - HEAP WPO NUMBER OF PEOPLE ASSISTED

                                                                                                                  1     Total Number of People Assisted (count each person only once)            #

  1   Elderly (60 Years or Older)                                                            #                 214 - HEAP AVERAGE HOUSEHOLD ENERGY BURDEN

  2   Disabled                                                                               #                          From the Intake applications, calculate the average energy burden
                                                                                                                  1                                                                                           %
  3   Age 5 Years or Under (This is NOT a total of lines 4 and 5)                            #                          percentage of WPO households assisted during the reporting period.

  4   Age 2 Years and Under                                                                  #
  5   Age 3 Years Through 5 Years                                                            #
  6   Dwellings with Seasonal/Migrant Farm Workers                                           #

  7   Dwellings with Limited English-Speaking Persons                                        #                        1 The totals should match in Sections 205 and 211.
  8   Dwellings with Native American Indians                                                 #                        2 Dwelling(s) and/or people assisted may be more than one type

211- HEAP NUMBER OF HOUSEHOLDS ASSISTED BY ENERGY BURDEN
(Unduplicated - Include all households served, both vulnerable population and non-vulnerable population.)

  1   Range: From 0% to 5.0%                                                                 #

  2   Range: From 5.1% to 10%                                                                #

  3   Range: From 10.1% to 15%                                                               #
  4   Range: From 15.1% to 20%                                                               #
  5   Range: From 20.1% to 25%                                                               #

  6   Range: From 25.1% and higher                                                           #
                                                                                         1
  7                                         Total Households Assisted by Energy Burden       #
State of California                                                                                                                                                                                   Page 6 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                    2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                  Contract Number:                                          Report Period:                         Adjustment


                                                     SEVERE WEATHER ENERGY ASSISTANCE AND TRANSPORTATION SERVICES (SWEATS) 2

215- SWEATS RECIPIENTS - NUMBER OF HOUSEHOLDS ASSISTED WITH GROSS MONTHLY                       217 - SWEATS RECIPIENTS - NUMBER OF PEOPLE ASSISTED
INCOMES (Transfer totals from the Energy Crisis Intervention Intake Form)                         1.     Total Number of People Assisted (Count each person only once)                        #

 1.   Under 75%                                                                         #       218 - SWEATS RECIPIENTS - SERVICED DWELLINGS BY TYPE

 2.   75% - 100%                                                                        #         1.     Single Family Site-Built - Owner Occupied                                            #

 3.   101% - 125%                                                                       #         2.     Single-Family Site-Built - Rental                                                    #

 4.   126% - 150%                                                                       #         3.     Multi-Unit (two to four units)                                                       #

 5.   Over 150%                                                                         #         4.     Multi-Unit (five or more units)                                                      #

 6.                                                                                     1         5.     Mobile Home - Owner-Occupied                                                         #
                                    Total Households Assisted With Gross Monthly Incomes #

216- SWEATS RECIPIENTS - NUMBER OF HOUSEHOLDS ASSISTED WITH AT LEAST ONE MEMBER                   6.     Mobile Home - Rental                                                                 #
WHO IS: (Households may be counted in more than one category).                                                                                                                            1
                                                                                                  7.                                                   Total Serviced Dwellings by Type       #
 1.   Elderly (60 Years or Older)                                                       #

 2.   Disabled                                                                          #

 3.   Age 5 Years or Under (This is NOT a total of lines 4 and 5)                       #

 4.   Age 2 Years and Under                                                             #

 5.   Age 3 Years Through 5 Years                                                       #

 6.   Age 6 Years Through 18 Years                                                      #              1 The totals for Households Assisted with Gross Monthly Incomes in Section 215 should match with
                                                                                                         Dwellings by Type in Section 218 .
 7.   Seasonal/Migrant Farm Workers                                                     #

 8.   Limited English-Speaking Persons                                                  #              2 Reporting excludes transportation services.

 9.   Native American Indians                                                           #
State of California                                                                                                                                                                                                   Page 7 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                        2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                                   Contract Number:                           Report Period:                         Adjustment


                                                                                                               ECIP EHCS
                                                                                                                               Unit of Measure or   Rate or Materials
220 - ECIP EHCS COOLING PROGRAM COSTS                                                                         Dwellings                                                    Subcontractor        Other Labor       Expenditure
                                                                                                                                     Labor               or Fees

 1. A/C Unit Repair, FAU, Split System (Max. $1320 or 50% of Repl. Per Dwelling)                         #                    L                     +M                    +S               +O                 $
1a. A/C Unit Repair, Multi-Unit Central Sys (Max 597 per MUD) Eff. 1/1/09                                #                    L                     +M                    +S               +O                 $
 2. A/C Unit Repair, Wall/Window (Max $597 or 50% of Repl)                                               #                    L                     +M                    +S               +O                 $
 3. A/C Unit Replace, FAU, Split System (Max. $2640 Per Dwelling)                                        #                    L                     +M                    +S               +O                 $
3a. A/C Unit Replace, Multi-Unit Central Sys (Max. $1194 per MUD) Eff 1/1/09                             #                    L                     +M                    +S               +O                 $
 4. A/C Unit Replace, Wall/Window (Max. $1194 Per Dwelling)                                              #                    L                     +M                    +S               +O                 $
 5. A/C Unit Replace, Multi-Story 110V Wall Unit (Max. $942) Thru 12/31/08                               #                    L                     +M                    +S               +O                 $
 6. A/C Unit Replace, Single-Story 110V Wall Unit (Max. $816) Thru 12/31/08                              #                    L                     +M                    +S               +O                 $
 7. A/C Unit Replace, Single-Story 110V Window Unit (Max. $624) Thru 12/31/08                            #                    L                     +M                    +S               +O                 $
 8. A/C 220V Wall Unit, Replace (Max. $1329 Per Dw) Thru 12/31/08                                        #                    L                     +M                    +S               +O                 $
 9. A/C 220V Window Unit, Replace (Max. $1077 Per Dw) Thru 12/31/08                                      #                    L                     +M                    +S               +O                 $
10. Cooling Source Repair, Other Types (Max. $250 Per Dwelling) Thru 12/31/08                            #                    L                     +M                    +S               +O                 $
11. Cooling Source Replacement, Other Types (Max. $500 Per Dw) Thru 12/31/08                             #                    L                     +M                    +S               +O                 $
12. Evaporative Cooler Replacement- Roof Unit (Max. $1100 Per Dwelling)                                  #                    L                     +M                    +S               +O                 $

13. Evaporative Cooler Installation-New Wall Unit (Max. $850 Per Dw)Thru 12/31/08                        #                    L                     +M                    +S               +O                 $

14. Evaporative Cooler Replacement- Window/Wall Unit (Max. $936 Per Dwelling)                            #                    L                     +M                    +S               +O                 $
15. Evaporative Cooler Installation-Replace Roof Unit (Max. $1020) Thru 12/31/08                         #                    L                     +M                    +S               +O                 $

16. Evap Cooler Install, Replace Wall Unit (Max. $786) (Thur 7-31-08)                                    #                    L                     +M                    +S               +O                 $

16a. Evap Cooler Install, Replace Wall Unit (Max. $900) (Thru 12/31/08)                                  #                    L                     +M                    +S               +O                 $

17. Evap Cooler Install, Replace Window Unit (Max. $786) (Thru 7-31-08)                                  #                    L                     +M                    +S               +O                 $
17a. Evap Cooler Install, Replace Window Unit (Max. $900) (Thru 12/31/08)                                #                    L                     +M                    +S               +O                 $

18. Evaporative Cooler Repair (Max. $550 or 50% of Repl. Per Dwelling)                                   #                    L                     +M                    +S               +O                 $
                                                                                                                                                                    Total ECIP EHCS Cooling Program Costs $
    Adjustments only: Enter reporting period being adjusted. Insert only increase or decrease on each line item being revised using + or - sign.
State of California
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                               2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                                                   Contract Number:                             Report Period:                        Adjustment


                                                                                                                      ECIP EHCS

                                                                                                                                                   Unit of Measure or Rate or Materials
225 - ECIP EHCS HEATING PROGRAM COSTS                                                                                         Dwellings                                                     Subcontractor    Other Labor          Expenditu
                                                                                                                                                         Labor             or Fees

 1 Heating Source Repair, Ext Wall Direct Vent Furn. (Max. $540) Thru 12/31/08                                           #                     L                      +M                  +S                +O                $
1a. Heating Source Repair, Ext Wall Direct Vent, Int Wall, Floor Furnace (Max. $792)(Eff 1-1-09)                         #                     L                      +M                  +S                +O                $
 2 Heating Source Repair, FAU, Split Sys (Max. $1044)                                                                    #                     L                      +M                  +S                +O                $
2a. Heating Source Repair, Multi-Unit Central Sys ($792 per MUD) Eff. 1/1/09                                             #                     L                      +M                  +S                +O                $
 3 Heating Source Repair, Floor Furnace (Max. $621) Thru 12/31/08                                                        #                     L                      +M                  +S                +O                $
 4 Heating Source Repair, Interior Wall Furnace (Max. $792) Thru 12/31/08                                                #                     L                      +M                  +S                +O                $
 5 Heating Source Repair, Mobile Home Furnace (Max. $742 or 30% of Repl. Per Dwelling)                                   #                     L                      +M                  +S                +O                $
 6 Heating Source Repair, Other Types (Max. $1080 or 30% of Repl. Per Dwelling)                                          #                     L                      +M                  +S                +O                $
 7 Heating Source Repair, Package Unit (Dual Pack) (Max. $1530 or 30% of Repl. Per Dwelling)                             #                     L                      +M                  +S                +O                $
 8 Heating Source Repair, Wood Fueled Appliance (Max. $1080 or 30% of Repl. Per Dwelling)                                #                     L                      +M                  +S                +O                $
 9 Heating Source Replace, Ext.Wall Direct Vent Furnace (Max. $1800) Thru 12/31/08                                       #                     L                      +M                  +S                +O                $
9a. Heating Source Replace, Ext. Wall Direct Vent, Int Wall, Floor Furn (Max $2640 (Eff 1/1/09)                          #                     L                      +M                  +S                +O                $
10 Heating Source Replacement, FAU, Split System (Max. $3480 Per Dwelling)                                               #                     L                      +M                  +S                +O                $

10a. Heating Source Replacement, Multi-Unit Central Ssytem (Max. $2640 per MUD)                                          #                     L                      +M                  +S                +O                $

11 Heating Source Replacement, Floor Furnace (Max. $2070) Thru 12/31/08                                                  #                     L                      +M                  +S                +O                $
12 Heating Source Replacement, Interior Wall Furnace (Max. $2640) Thru 12/31/08                                          #                     L                      +M                  +S                +O                $

13 Heating Source Replacement, Mobile Home Furnace (Max. $2472 Per Dwelling)                                             #                     L                      +M                  +S                +O                $
14 Heating Source Replacement, Other Types (Max. $3600 Per Dwelling)                                                     #                     L                      +M                  +S                +O                $
15 Heating Source Replacement, Package Unit (Dual Pack) (Max. $5100 Per Dwelling)                                        #                     L                      +M                  +S                +O                $
15a. Heating Source Replacement, Wood Fueled Appliance (Max. $3600) Eff 1/1/09                                           #                     L                      +M                  +S                +O                $
16 Duct Repair and Replacement (Max. $1223 Per Dwelling)                                                                 #                     L                      +M                  +S                +O                $

17 Duct Leakage Pre-Test (with Duct Blaster Only)                                                                        #                                            X           60.00                                       $

18 Duct Leakage Post-Test (with Duct Blaster Only)                                                                       #                                            X           50.00                                       $
                                                                                                                                                                                 Total ECIP EHCS Heating Program Costs $
    Adjustments only: Enter reporting period being adjusted. Insert only increase or decrease on each line item being revised using + or - sign.
                                                     Page 8 of 11


REIMBURSEMENT/ACTIVITY REPORT
                                   Adjustment


     ECIP EHCS

                                                Expenditures




being revised using + or - sign.
State of California                                                                                                                                                                                        Page 9 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)

                                                                           2008 LIHEAP EHA-16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                      Contract Number:                       Report Period:                               Adjustment


                                                                                                 ECIP HCS

                                                                                                              Unit of Measure or   Rate or Materials
227 - ECIP EHCS WATER HEATING COSTS                                                              Dwellings                                                    Subcontractor         Other Labor       Expenditures
                                                                                                                    Labor               or Fees

 1    Electric Water Heater Repair (Max. $350 or 50% of Repl. Per Dwelling) (Thur 7-31-08)   #               L                     +M                    +S                    +O                 $
 1a. Electric Water Heater Repair (Max. $490 or 50% of Repl. Per Dwelling) (Eff 8-1-08)      #               L                     +M                    +S                    +O
 1b. Multi-Unit Central Ssytem, Water Heater Repair (Max. $490) Eff. 1/1/09                  #               L                     +M                    +S                    +O
 2    Gas Water Heater Repair (Max. $490 or 50% of Repl. Per Dwelling)                       #               L                     +M                    +S                    +O
 3    Electric Water Heater Replacement (Max. $700 Per Dwelling) (Thru 7-31-08)              #               L                     +M                    +S                    +O
 3a. Electric Water Heater Replacement (Max. $980 Per Dwelling) (Effective 8-1-08)           #               L                     =M                    +S                    +O
 4    Gas Water Heater Replacement (Max. $980 Per Dwelling)                                  #               L                     +M                    +S                    +O
 5    Multi-Unit Central Ssytem, Water Heater Replacement (Max. $980) Eff. 1/1/09            #               L                     +M                    +S                    +O
                                                                                                                                                                 Total ECIP Water Heating Costs $
230 - ECIP EHCS OTHER PROGRAM COSTS
 1    Disposal Fees                                                                          #               L                     +F                    +S                    +O                 $
 2    Permits                                                                                #               L                     +F                    +S                    +O
 3    HERS Rater                                                                             #                                                           +S                    +O
 4    Lead-Safe Weatherization Materials                                                     #                                     +M
 5    Single-Family Dwelling (1 to 4 Units)                                                  #                                     A
 6    Additional Reimbursement - SFD (Thru 7-31-08)                                          #                                     X              8.00
 6a. Additional Reimbursement - SFD (Effective 8-1-08)                                       #                                     X            18.00
 7    Multi-Unit Dwelling (5 or More Units) (Thru 7-31-08)                                   #                                     X              3.50
 7a. Multi-Unit Dwelling (5 or More Units) (Effective 8-1-08)                                #                                     X              8.50
 8    Mileage Outside of 60-Mile Round Trip (Thru 7-31-08)                                   #                   #                 X              0.81
 8a. Mileage Outside of 60-Mile Round Trip (Effective 8-1-08)                                #                   #                 X              0.91
 9    Lodging and Per Diem                                                                   #                                     +F
235 - CSD APPROVED LRI TRAVEL COSTS
 1    Single Family Dwelling (1 to 4 Units) Enter total dwelling) (Thru 12-31-08)                                                                                                                 #
236 - LRI TRAVEL COSTS
 1    LRI Travel Total: (Thru 12-31-08)                                                                                   Input onlyTotal LRI (Do Not Enter Full Labor Rate)    $                 $
237 - 2009 CSD APPROVED LRI TRAVEL COSTS
 1.   Single Family Dwelling (1 to 4 Units) Enter total dwelling) (Effective 1-1-09)                                                                                                              #
238 - 2009 LRI TRAVEL COSTS
 1.   LRI Travel Total: (Effective 1-1-09)                                                                                Input onlyTotal LRI (Do Not Enter Full Labor Rate)    $                 $
                                                                                                                                               Total ECIP EHCS Other Program Costs $


Adjustments only: Enter reporting period being adjusted. Insert only increase or decrease on each line item being revised using + or - sign.
State of California                                                                                                                                                                                                  Page 10 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                         2008 LIHEAP EHA-A16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                              Contract Number:                             Report Period:                             Adjustment

                                                              SEVERE WEATHER ENERGY ASSISTANCE AND TRANSPORTATION SERVICES (SWEATS)
                                                                                                                            Unit of Measure or   Rate or Materials
240 - SWEATS PROGRAM COSTS                                                                               Dwellings                                                          Subcontractor     Other Labor         Expenditures
                                                                                                                                  Labor               or Fees

 1.    Portable Equipment Purchased and Held on Reserve - Air Conditioner                                               #                        +M                                                           $
 2.    Portable Equipment Purchased and Held on Reserve - Evaporative Cooler                                            #                        +M                                                           $
 3.    Portable Equipment Purchased and Held on Reserve - Heater                                                        #                        +M                                                           $
 4.    Portable Equipment Purchased and Held on Reserve - Fan                                                           #                        +M                                                           $
 5.    Portable Equipment Purchased and Held on Reserve - Generator                                                     #                        +M                                                           $
 6.    Portable Equipment Purchased and Held on Reserve - Other                                                         #                        +M                                                           $
 7.    Repair and Maintenance of Reserve Appliances - Air Conditioner*                               #                  L                        +M                    +S                   +O                $
 8.    Repair and Maintenance of Reserve Appliances - Evaporative Cooler*                            #                  L                        +M                    +S                   +O                $
 9.    Repair and Maintenance of Reserve Appliances - Heater*                                        #                  L                        +M                    +S                   +O                $
10.    Repair and Maintenance of Reserve Appliances - Fan*                                           #                  L                        +M                    +S                   +O                $
11.    Repair and Maintenance of Reserve Appliances - Generator*                                     #                  L                        +M                    +S                   +O                $
12.    Repair and Maintenance of Reserve Appliances - Other*                                         #                  L                        +M                    +S                   +O                $
13.    Additional Reimbursement - Fees, Fares, or Costs for Rental Vehicles                          #                                           +F                                                           $
14.    Mileage to Cooling Centers or Hotels (Thru 7-31-08)                                           #                  #                        X              0.81                                          $
14a.   Mileage to Cooling Centers or Hotels (Effective 8-1-08)                                       #                  #                        X              0.91                                          $
15.    Temporary Shelter/Housing (Maximum 5 days)                                                    #                                           +F                                                           $
16.    Utility Assistance Payment (Maximum $1,000)                                                   #                                           +F                                                           $
17.    Other, personal tangible individual benefits (coats, blankets)                                #                                           +F                                                           $
                                                                                                                                                                                 Total SWEATS Program Costs $
241 - SWEATS LOANED APPLIANCES PROGRAM COSTS
 1.    Portable Equipment Delivered on Loan to a Dwelling - Air Conditioner                          #                  L                                              +S                   +O                $
 2.    Portable Equipment Delivered on Loan to a Dwelling - Evaporative Cooler                       #                  L                                              +S                   +O                $
 3.    Portable Equipment Delivered on Loan to a Dwelling - Heater                                   #                  L                                              +S                   +O                $
 4.    Portable Equipment Delivered on Loan to a Dwelling - Fan                                      #                  L                                              +S                   +O                $
 5.    Portable Equipment Delivered on Loan to a Dwelling - Generator                                #                  L                                              +S                   +O                $
 6.    Other Emergency Services                                                                      #                  L                        +M                    +S                   +O                $
 7.    Single-Family Dwelling (SFD) (1 to 4 Units)                                                   #                                           A                                                            $
 8.    Additional Reimbursement - SFD (Thru 7-31-08)                                                 #                                           X              8.00                                          $
 8a. Additional Reimbursement - SFD (Effective 8-1-08)                                               #                                           X            18.00                                           $
 9.    Multi-Unit Dwelling (MUD) (5 or More Units) (Thru 7-31-08)                                    #                                           X              3.50                                          $
 9a. Multi-Unit Dwelling (5 or More Units) (Effective 8-1-08)                                        #                                           X              8.50                                          $
10.    Mileage Outside of 60-Mile Round Trip (Thru 7-31-08)                                          #                  #                        X              0.81                                          $
10a.   Mileage Outside of 60-Mile Round Trip (Effective 8-1-08)                                      #                  #                        X              0.91                                          $
11.    Fuel for Generators                                                                           #                  L                        +M                    +S                   +O          $
                                                                                                                                                           Total SWEATS Loaned Appliances Program Costs $
       *Section 240, Lines 7-12, enter the number of reserve applicances that received repair or maintenance under the Dwellings column.

            Adjustments only: Enter reporting period being adjusted. Insert only increase or decrease on each line item being revised using + or - sign.
State of California                                                                                                                                                                                                              Page 11 of 11
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 670 (Rev. 2/16/09)
                                                                          2008 LIHEAP EHA-A16 REIMBURSEMENT/ACTIVITY REPORT
Contractor:                                                                                                      Contract Number:                               Report Period:                                  Adjustment

                                                            SEVERE WEATHER ENERGY ASSISTANCE AND TRANSPORTATION SERVICES (SWEATS)
242 - CSD APPROVED LRI SWEATS TRAVEL COSTS

 1    Single Family Dwelling (1 to 4 Units) Enter total dwelling) (Thru 12-31-08)                                                                                                                                            #

243 - LRI SWEATS TRAVEL COSTS

 1    LRI SWEATS Travel Total:                                                                                                                        Input labor rate increase only NOT total labor rate   $                $
243.1 - 2009 CSD APPROVED LRI TRAVEL COSTS
 1.   Single Family Dwelling (1 to 4 Units) Total SFD from Section 241 #7 (Effective 1-1-09)                                                                                                                                 #
243.2 - 2009 LRI TRAVEL COSTS
 1.   LRI Travel Total: (Effective 1-1-09)                                                                                                           Input onlyTotal LRI (Do Not Enter Full Labor Rate)     $                $
244 - TOTAL SWEATS PROGRAM COSTS
 1.                                                                                                                                                         Total SWEATS Program Costs (Sections 240, 241 and 243.2) $
      Adjustments only: Enter reporting period being adjusted. Insert only increase or decrease on each line item being revised using + or - sign.

								
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