Form Hud-50080-Mtw Loccs / Vrs Moving To Work Demonstration Program Technical Assistance Grants Payment Voucher

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OMB Approval No. 2577-0166 (exp. 9/30/2010)

U.S. Department of Housing

LOCCS / VRS

and Urban Development

Moving to Work

Office of Public and Indian Housing

Demonstration Program

Technical Assistance Grants

Payment Voucher

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.

HUD implemented the Line of Credit Control System/Voice Response System (LOCCS/VRS) to process requests for payments to grantees. Grant

recipients fill out a voucher form for the applicable HUD program with all the necessary information prior to making a telephone call using a touch tone

telephone to initiate the drawdwon process. The grantee will be prompted for entering the information and for confirming information that is spoken back

by the VRS simulated voice. This information is required to obtain benefits under the U.S. Housing Act of l937, as amended. The information requested

does not lend itself to confidentiality.

1. Voucher/Certification Number

2. LOCCS Pgrm. Area

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

1 = Partial Disbursement

094

MTWG

2 = Final Disbursement

from:

to:

5. Voice Response No. (5 digits, hyphen, 5 more )

6. Grantee Organization's Name

7. Payee Organization's Name

8. Grant No

6a. Grantee Organization's TIN No.

7a. Payee Organization's TIN

9. Line Item No.

Type of Funds Requested

Amount (dollars)

* (cents)

0100

MTW Technical Assistance

10. Voucher/Certification 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)

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

of the Person who called:

13. Signature :

14. Date of Request :

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)

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 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.

form HUD-50080-MTW (3/2001)