HUD 40099 TCAP IDIS Access Requiest Form

OMB Approval Pending

IDIS Access Request – TCAP ONLY

This form is to be completed by the recipient’s (or grantee’s) chief executive officer or designated representative. Send notarized original to the Office of Affordable Housing Programs.

Public reporting burden for this collection of information is estimated to average .25 hours.  This includes the time for collecting, reviewing, and reporting the data.  The information is being collected for IDIS and will be used for IDIS access.  Response to this request for information is required in order to receive the benefits to be derived.  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.

Privacy Act 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 which will be used by HUD to protect disbursement data from fraudulent actions. The purpose of the data is to safeguard the Integrated Disbursement and Information System (IDIS) from unauthorized access. The data are used to ensure that individuals who no longer require access to IDIS have their access capability promptly deleted. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Failure to provide the information requested on the form may delay the processing of your approval for access to IDIS.

Action

New Request Renew Lapsed ID Drop From IDIS

Information

Authorized User’s Name (Last, First, MI):	E-mail Address:
     	     
Social Security Number (SSN):	Office Phone:
     	     
Office Address:	UOG Code:
     	     
Grantee Organization’s Name:
     

Please Mark All Necessary Authorized Functions:

Set Up Activity Request Drawdown Approve Drawdown

Note: Every IDIS user can view activities and generate reports even if no functions are authorized.

Authorization

Authorized User’s Signature Date

HHQ Approval (OAHP Date

Director or Designee)

(Note: You can’t authorize yourself, only your CEO or “grant holder” can.) I authorize the person above to access IDIS, with the functions checked.

Notary (signature and date)

Approved by:	Name:      
	Title:     
Office Address:	Street		City	ST	ZIP
	     		     	     	     
	Office Phone:      

Approving Official’s Signature Date

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)

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