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

U.S. Department of Housing

LOCCS / VRS

and Urban Development

Tenant Opportunities Program

Office of Public and Indian Housing

Payment Voucher

(All Grantees)

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 Number

2. LOCCS Pgrm. Area

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

025

TOP

from

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

6. Grantee Organization's Name

8. Grant or Project No.

6a. Grantee Organization's TIN

Line Item No.

Type of Funds Requested

Amount (dollars)

(cents)

9810

Employment Readiness Training Contract

9820

Business/Job Training Contracts

9830

Job Placement Retention Contracts

9840

Mediation Activities

9850

Resident Organization Development Activities

9851

Organize Community

9852

Operating Procedures

9853

Develop MOU

9854

Plan for Technical Assistance

9855

Consultant Contracts

9856

Implement Property Management

9857

Self-Sufficiency Programs

9860

Travel Costs

9870

Other Resident Costs (Stipends, Reimbursements)

9880

Administrative and Other Costs

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)

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.

Previous editions are obsolete

form HUD-50080-TOP

(4/2000)

Form Hud-50080-Top - Loccs / Vrs Tenant Opportunities Program Payment Voucher (All Grantees)

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