Form Hud-50080-Itg - Payment Voucher - Intermediary Technical Assistance Grants - Office Of Housing Federal Housing Commissioner - U.s. Department Of Housing And Urban Development - 2010

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U.S. Department of Housing

LOCCS / VRS

OMB Approval No. 2577-0166

(exp. 9/30/2010)

and Urban Development

Intermediary Technical

Office of Housing

Federal Housing Commissioner

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 drawdown 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

M2M

084

2 = Final Disbursement

from

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

(dollars)

(cents)

0110

Resident Capacity

- Tenant Outreach and Training Activities

0120

Resident Capacity

- Property Assessment Activities

0130

Resident Capacity

- Organization's Administrative Activities

0210

Predevelopment

- Tenant Outreach and Training Activities

0220

Predevelopment

- Property Assessment Activities

0230

Predevelopment

- Organization's Administrative Activities

0310

Public Entity

- Tenant Outreach and Training Activities

0320

Public Entity

- Property Assessment Activities

0330

Public Entity

- Organization's Administrative Activities

Subtotal of all above line items

0410

5% Administrative Fee

- 5% X the subtotal above

0420

Application Rejection Fee(s)

- $600 per Rejection

0430

One-Time Start-Up Fee

- $40,000

0440

Sub-recipient Monitoring Activities

10. Voucher Total (Sum of Subtotal and lines 0410 thru 0440)

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 completed this form

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-ITG (4/2000)