Form Hud-50080-Scmf - Loccs / Vrs Payment Voucher Service Coordinators For Multifamily Housing

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U.S. Department of Housing

OMB Approval No. 2502-0447

LOCCS / VRS Payment Voucher

(exp 9/30/2010)

and Urban Development

Service Coordinators for

Office of Housing

Federal Housing Commissioner

Multifamily Housing

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.

Send

commentsregarding this burden estimate or any other aspect of this collection in information, including suggestions for reducing this burden, to the Reports

Management Officer, Paperwork Reduction Project (2577-0166), Office of Information Technology, U.S. Department of Housing and Urban Development,

Washington, DC 20140-3600. 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. Do not send this form to the above address.

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 Number

2. LOCCS Pgrm. Area

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

1 = Partial Disbursement

085

SCMF

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 or Project No.

6a. Grantee Organization's TIN

7a. Payee Organization's TIN

Line Item No.

Type of Funds Requested

Amount

1010

Salary

1020

Fringe Benefits

1030

Administration

1040

Quality Assurance

1045

Training

1050

Travel

1055

Supplies & Materials

1060

Start-up Costs

1065

Other Direct Costs

1070

Indirect Costs

0.00

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 and Phone Number (including area code)

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

of the person who completed this form

13. Signature

14. Date of Request (mm/dd/yyyy)

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-SCMF (5/2004)