Form Hud-50080-Homi - Indian Home Program Payment Certification Voucher

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LOCCS / VRS

U.S. Department of Housing

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

and Urban Development

Indian HOME Program

Office of Public and Indian Housing

Payment Certification

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. Send comments

regarding this burden estimate or any other aspect of this collection of 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, D.C.

20410-3600. 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/Certification Number :

2. LOCCS Pgrm. Area:

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

1 = Partial Disbursement

027

HOMI

2 = Final Disbursement

from:

to:

5. Voice Response No. (5 digits, hyphen, 5 more ) : 6. Indian Tribe's Name :

7. Payee Organization's Name :

8. Grant No:

6a. Indian Tribe's Taxpayer ID No. :

7a. Payee Organization's TIN:

Line Item No.

Type of Funds Requested

Amount : (dollars)

(cents)

1000

Non-Administrative Costs

2000

Administrative Costs

Voucher/Certification Total:

10.

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-HOMI (4/2000)