HUD-50080-IHBG Indian Housing Block Grant Payment Voucher

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

LOCCS / eLOCCS
Indian Housing Block Grant
Payment Voucher

OMB Approval No. 2577-0166 (exp. 01/31/2021)

This information is required to obtain benefits under the Native American Housing Assistance and Self-Determination Act of 1996. Reporting burden is
estimated at 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 collect this information, and you are not required to complete this
form, unless it displays a currently valid OMB control number. The information requested does not lend itself to confidentiality. The Line of Credit Control System
(LOCCS) is HUD’s primary grant and subsidy disbursement system for the majority of HUD programs. Organizations and individuals have access to these grants
through an internet version of LOCCS called eLOCCS, where authorized Business Partners can access, manage, and drawdown grant funds. LOCCS is accessed
through the internet portal, Secure Systems, the combination of the two systems is eLOCCS.

1. Voucher Number

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

2. LOCCS Pgrm. Area

079

IHBG

from:

5. Not applicable

6. Grantee Organization's Name

8. Grant or Project No.

6a. Grantee Organization's TIN

9. Line Item No.

to:

Amount

Type of Funds Requested

1600

Current Assisted Stock Operating Subsidy

1601

Investments

1602

IHBG Balance

10. Voucher Total

(dollars)

*

(cents)

$

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 Completed this Form:

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

13. Signature :

14. Date of Request :

X

Warning: I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false
statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)
Privacy Statement: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The authority for collecting personally identifiable information (PII) in the Regulatory Consistency
Communication Board (RCCB) Electronic Feedback Form is based in Section 313 of Public Law 112­95. 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.

form HUD-50080-IHBG (09/2017)