HUD-50080hom LOCCS/VRA Indian HOME Program Payment Certification Vouc

LOCCS / VRS
Indian HOME Program
Payment Certification
Voucher

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

OMB Approval No. 2577-0166 (exp.7/31/2007)

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Management
Officer, Paperwork Reduction Project (2577-0166), Office of Information Technology, U.S. Department of Housing and Urban Development, Washington, D.C.
20410-3600. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
Do not send this form to the above address.
HUD implemented the Line of Credit Control System/Voice Response System (LOCCS/VRS) to process requests for payments to grantees. Grant recipients
fill out a voucher form for the applicable HUD program with all the necessary information prior to making a telephone call using a touch tone telephone to initiate
the drawdwon process. The grantee will be prompted for entering the information and for confirming information that is spoken back by the VRS simulated
voice. This information is required to obtain benefits under the U.S. Housing Act of l937, as amended. The information requested does not lend itself to confidentiality.
1. Voucher/Certification Number :

2. LOCCS Pgrm. Area:

027

3. Period Covered by this Request (mm/yy):

HOMI

from:

4.

1 = Partial Disbursement
2 = Final Disbursement

to:

5. Voice Response No. (5 digits, hyphen, 5 more ) : 6. Indian Tribe's Name :

7. Payee Organization's Name :

8. Grant No:

7a. Payee Organization's TIN:

9. Line Item No.

6a. Indian Tribe's Taxpayer ID No. :

Type of Funds Requested

Amount : (dollars)

*

1000

Non-Administrative Costs

*

2000

Administrative Costs

*

(cents)

*
*
*
*
*
*
*
*
*
*
10. Voucher/Certification

Total:

$

*

I certify the data reported and funds requested on this voucher are correct and the amount requested is not in excess of immediate disbursement needs
for this program. In the event the funds provided become more than necessary, such excess will be promptly returned, as directed by HUD.
11. Name & Phone Number (including area code)
of the Person who called:

12. Name & Title of Authorized Signatory (type or print clearly) :

13. Signature :

14. Date of Request :

X
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Privacy Statement: Public Law 97-255, Financial Integrity Act, 31 U.S.C. 3512, authorizes the Department of Housing and Urban Development (HUD) to
collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions. The
purpose of the data is to safeguard the Line of Credit Control System (LOCCS) from unauthorized access. The data are used to ensure that individuals who
no longer require access to LOCCS have their access capability promptly deleted. Failure to provide the information requested on the form may delay the
processing of your approval for access to LOCCS. While the provision of the SSN is voluntary, HUD uses it as a unique identifier for safeguarding the LOCCS
from unauthorized access. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.
form HUD-50080-HOMI (4/2000)