HUD-301 Request and Payment for Labels

Request and Payment
for Labels

U.S. Department of Housing and Urban Development

OMB Approval No. 2502-0233

Office of Manufactured Housing Programs

expires 08/31/2019

The Manufactured Housing Procedural and Enforcement Regulations 24 CFR Chapter XX Part 3282 Section 552 requires manufacturers to report certification
label usage on a monthly basis. The information collected here will be used to report home distribution, collect fees, and reimburse parties as appropriate under
these Regulations. Public reporting burden for this collection of information is estimated to average 0.5 hours 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. Response to
this information collection is mandatory. 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. There are no assurances of confidentiality.
Manufacturer’s Name & Address

Factory Name & Address

Manufacturer’s Representative

Phone

Date (mm/dd/yyyy)

Manufacturer’s Request
(to be completed by manufacturer)

We hereby request that our IPIA, _________for this manufacturing factory issue

manufactured home certification labels.
(quantity)

X $100.00

Total number of labels requested
(quantity)

=

$

-

$

(Fee/Label)

Credit adjustment (include Form 303 with credit)
Payment Amount (for HUD’s Certification Label Fee)

$

Payment Receipt Number (Provided by Pay.gov)

dated
(mm/dd/yyyy)

IPIA Assignment of Label Numbers
(to be completed by IPIA)

The following unissued certification label numbers are assigned to the specific facility identified above.
Certification Labels

-

through & including

-

=

(Quantity)

Certification Labels

-

through & including

-

=

(Quantity)

Certification Labels

-

through & including

-

=

(Quantity)

Total number of labels issued

X $100.00

(Fee/Label)

=

IPIA Authorized Label Administrator
(signature)

(mm/dd/yyyy)

Tender payment through Pay.gov and send copy of form and payment receipt.

Previous editions obsolete

Form HUD-301 (09/16)