HUD-50080-PHTA Public Housing Technical Assistance Payment Voucher

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

LOCCS / eLOCCS
Public Housing
Technical Assistance
Payment Voucher

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

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 collect
this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

The Line of Credit Control System (LOCCs) is HUD's primary grant and subsidy disbursement system for most 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 an Internet Portal Secure Systems. The combination of the two systems is eLOCCS.

1. Voucher Number

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

2. LOCCS Pgrm. Area

049

PHTA

from

5. Voice Response No. (5 digits, hyphen, 5 more ) 6. Grantee Organization's Name

8. Grant or Project Number

9. Line Item No.

6a. Grantee Organization's TIN

4.

1 = Partial Disbursement
2 = Final Disbursement

to

7. Payee Organization's Name

7a. Payee Organization's TIN

Type of Funds Requested

Amount : (dollars)

*

(cents)

*
*
*
*
*
*
*
*
*
*
*
*
$
10. Voucher Total

*

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, 101
0, 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 312 of Public Law 112-95. 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-PHTA

(09/2017)