Form HUD-90198 Payment Voucher

LOCCS/VRS
Congregate Housing Services Program
Payment Voucher
1. Voucher Number :

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0485 (exp.1/31/2015)

Please read the Instructions and 123456789012345678901234567890121234567
the Public Reporting Statement before completing this form

2. LOCCS Pgrm. Area: 123456789012345678901234567890121234567
3. Period Covered by this Request:
4. Type of Disbursement:
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123456789012345678901234567890121234567
123456789012345678901234567890121234567
1 = Partial
2 = Final
123456789012345678901234567890121234567
12345678901234567890123456789012123456
12345678901234567890123456789012123456
5. Voice Response No. (5 digits, hyphen, 5 more ) : 6. Grantee Organization's Name :
7.
Payee
Organization's
Name:
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12345678901234567890123456789012123456
12345678901234567890123456789012123456
12345678901234567890123456789012123456
8. Grant No:
6a. Grantee Organization's TIN :
7a. Payee Organization's TIN:
12345678901234567890123456789012123456
12345678901234567890123456789012123456
12345678901234567890123456789012123456

043

9. Line Item no.

CHSP

Type of Funds Requested

Reporting Period (Specify one)
Quarterly _______________
Monthly
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12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
1020
Meals
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
1030
Personal Assistance
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
1040
Housekeeping
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
1050
Transportation
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
1060
Other (Specify)
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
12345678901234567890123
1070
Administration
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12345678901234567890123
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1234567890123456789012345678901212345678901234567890123456789012123456
1234567890123456789012345678901212345678901234567890123456789012123456
10. Voucher Total:1234567890123456789012345678901212345678901234567890123456789012123456 $
1234567890123456789012345678901212345678901234567890123456789012123456
1234567890123456789012345678901212345678901234567890123456789012123456
1010

Amount :

Case Management

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*
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Approving Official (FmHA State Office only)

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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)
11. Name & Phone Number (including area code)
of the Person who Completed this Form:

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

13. Signature:

14. Date of Request :

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 Housing and Community Development Act of 1987, 42 U.S.C. 3543, authorizes HUD to collect the SSN. The data are used to ensure that individuals
who no longer require access to Line of Credit Control System (LOCCS) have their access capability promptly deleted. Provision of the SSN is mandatory.
HUD uses it as a unique identifier for safeguarding LOCCS from unauthorized access. Failure to provide the information requested may delay the processing
of your approval for access to LOCCS. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.
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form HUD-90198 (5\94)

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. This agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless that collecton displays a valid OMB control number. The information is
basic to the operations of the Congregate Housing Services Program. It supports statutory requirements and program and management controls that prevent
fraud, waste and mismanagement. The controls must be maintained as long as current grants are in operation. Section 802 of the National Affordable
Housing Act authorizes/requires matching funds and participant fee collections that are reported onthese forms. The rule at 24 CFR 700.155(d) requires
grantees to submit these forms. The information will be used by State/Area offices to ensure that grant funds are being used properly. This includes grantees’
expense of appropriate grant monies during each annual grant period and the use of grant funds to provide eligible activities to eligible residents, and to
ensure that statutory requirements are being met. Program staff use the information to compile annual program data. Grantees must complete forms and
report grant activity in order to continue receiving grant funds. Each grantee is required to maintain confidentiality of information related to any individual, per
the Privacy Act of 1974.

Instructions for the

Congregate Housing Services Program (CHSP)
CHSP Grant Payment Voucher:
The CHSP Payment Voucher form must be completed for
each request of CHSP grant funds. Prepare the Payment
Voucher form prior to calling HUD to request funds from the
Line of Credit Control System (LOCCS). Telephone the
Preservation Voice Response System (VRS) at (703) 3911400 and provide your security ID. After completing the call,
keep a copy of the form in the Grantee’s Program file. The
original of the form must be received by the Government
Technical Representative at the HUD Field Office/FmHA
State Office within five days after the call-in.

Instructions:
Item 1. Voucher Number: Provided by LOCCS / VRS at the time
of call-in.
Item 2. LOCCS Program Area: The program code (CHSP) is
preprinted in block 2.
Item 4. Type of Disbursement: Check "final" if this is the final
disbursement for this phase of Congregate Housing
Services Program Award. Otherwise, check "partial."
Item 5. Voice Response No: Enter the 10 digit Voice Response
Number assigned by HUD.
Item 6. Grantee Organization’s Name: Enter the lead applicant
identified in the grant agreement who is legally responsible for completion of the Congregate Housing Services
Program activities.
Item 6a. Grantee Organization's Tax Identification No: Enter
the Tax (employer) Identification Number shown in item 6
on Standard Form 424 of the Congregate Housing Services Application and the SF 1199A (direct deposit form).
Item 8. Grant Number: Enter the Grantee’s grant number shown
in the Grant Agreement.

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Item 9. Type of Funds Requested: Enter the amount requested in each category (boxes 1010 through 1070).
Specify monthly or quarterly reporting period (check
one) and fill in the reporting period. If Quarterly, it must
be either: 1/1-3/31, 4/1-6/30, 7/1-9/30, 10/1-12/31, or
portion thereof. If monthly, it must be from day one of
month to day 28, 29, 30, or 31, or portion thereof.
Item 10. Voucher Total: The voice response system (VRS) will
confirm the amounts requested in each line item and the
total amount requested at the end of the call-in.
Item 11. Name & phone number (including area code) of the
authorized person who completed the call-in to VRS. The
authorized person is shown on line 3 of form HUD-27054.
Item 12. Name and title of person authorized to approve/sign this
certification/voucher.
Item 13. Signature of the person identified in item 12.
Item 14. Date of this Request: Enter the date of the call-in to
request funds.

form HUD-90198 (5\94)