HUD-27053 Request for Voucher Grant Payment

U.S. Department of Housing
and Urban Development
Office of Administration

LOCCS VRS
Request Voucher
for Grant Payment

OMB Approval No. 2535-0102
(exp. 11/30/2016)

Public reporting burden for this collection of information is estimated to average 10 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. 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.
This information collection is to request payment of grant funds or to designate the appropriate officials who can have access to HUD voice activated
payment system. The HUD voice activated payment system has been especially designed to help the recipient when calling in for a request of funds and
improves the payment process so the recipient will know right away whether their request will be paid or not. This information collection is required
under 24 CFR Subpart C, 85.21 - Post Award Requirements, the information collection is needed in order to obtain or retain a benefit.
1. Voucher Number :

2. LOCCS Pgrm. Area:

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

4. Recipient Organization's Name :

to:
4b. Recipient Organization's Address:

4a.Recipient Organization's Employer Identification Number :

5. Balance on Hand :

$
Voice Response No. (5 digits, hyphen, 5 digits) :

6.

Grant or Project No:

Amount :

(dollars)

(cents)

(1)

-

*

(2)

-

*

(3)

-

*

(4)

-

*

(5)

-

*

(6)

-

*

(7)

-

*

(8)

-

*

(9)

-

*

(10)

-

*

$

Voucher Total:

0*

$

0

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and
accurate. 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)
7. Name & Title of Authorized Signatory (type or print clearly)

Signature

Date of Request

X
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 (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.
Retain this form in your records for audit purposes

form HUD-27053 (3/93)

Instructions for the Preparation and Submission of form HUD-27053, Request Voucher for Grant Payment
1. Enter a (9) digit two part number. Part 1 is the (3) digit prefix to
your program. (If you do not know your (3) digit program prefix,
contact your Program/Grant Officer). Part 2, the remaining (6)
digits, will be assigned by LOCCS/VRS during the telephone call.
The entire (9) digit number will have to be entered prior to ending
the call.
2. This block contains a maximum of 4-digit (xxxx) alpha/numeric
program area identifier as stated in block 5a of the HUD-27054,
LOCCS Voice Response Access Authorization Form.
3. Enter the period covered by this request.
4. Enter the recipient organization's name as stated on the grant
agreement.
4a. Recipient Organization's Employer Identification Number (EIN)
is the nine(9) digit number that is also known as the Tax
Identification Number (TIN) in LOCCS-VRS and the Claim or
Payroll ID Number on the SF-1199A.
4b. Enter recipient organization's mailing address.
5. Enter the current balance of cash on hand.

Retain this form in your records for audit purposes

6. Line 1: Enter the 10-digit VRS Number of the first project/grant for
which funds are being requested. The first five digits of this
number identify the grantee/recipient; the second five identify the
specific project/grant. The first five digits should always be the
same for a grantee/recipient. The second five digits should run
consecutively for succeeding projects/grants within the program.
Next, enter the HUD project/grant number for the project. This
entry is for confirmation purposes only and will not be entered into
LOCCS-VRS through the touch-tone pad. Instead, when the VRS
number is keyed in, the VRS simulated voice will speak the HUD
project/grant number for the caller to ensure the correct VRS
number was keyed. Finally, enter the amount requested for that
particular project/grant. Dollars should be entered tro the left of
the asterisk (*) and cents to its right.
Lines 2 through 10: List any other project grants in the same
HUD Program Area for which funds are to be requested. The total
amount requested is entered in the lower right hand corner of
Block 6.
7. Enter the authorizing signature and date of signature. The
authorizing signatory in Block 7 can not be the same person(s)
designated in Block 3 of the HUD-27054, LOCCS Voice Response Access Authorization Form.

form HUD-27053 (3/93)