Form Hud-40102-B - Implementation Grant Payment Voucher printable pdf download

U.S. Department of Housing

LOCCS/VRS

OMB Approval No. 2506-0128

(exp. 08/31/2003)

and Urban Development

HOPE 3

/ Single Family Homes Program

Office of Community Planning

and Development

Implementation Grant

Payment Voucher

1. Voucher Number

2. LOCCS Pgrm. Area

1 = Partial Disbursement

2 = Final Disbursement

023

HOP3

(for Property Costs Only)

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

6. Recipient Organization's Name

8. Grant No.

8a. Property No. (12 digits)

6a. Recipient Organization's TIN

Line Item no.

Type of Funds Requested

Amount

(round to nearest dollar)

Property

0110

Acquisition Costs for Recipient Purchase

Costs

0120

Closing Costs for Recipient Purchase and Sale of Properties

0130

Architectural & Engineering

0140

Rehabilitation

0150

Permanent Relocation

0160

Temporary Relocation of Homebuyer

0170

Financial Assistance to Homebuyer

0180

Closing Costs for Homebuyer Purchase (

)

include homebuyer's costs only

Program

0190

Legal Fees (

)

excluding closing costs

Costs

0200

Replacement Reserves

0205

Homebuyer Outreach and Selection

0210

Counseling & Training

0215

Property Management and Holding Costs

0220

Ongoing Training of Recipient Staff

0230

Economic Development

0240

Administrative Costs

0250

Other Program Activities: (

)

specify

10. Voucher Total

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.

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)

11. Name & Phone Number (including area code)

12. Signature

13. Date of Request

of the Authorized Person who called HOPE 3 C/MI System VRS

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 Housing

and Community Development Act of 1987, 42 U.S.C. 3543, authorizes HUD to collect the SSN. The data are used to ensure that individuals who no longer

require access to Line of Credit Control System (LOCCS) have their access capability promptly deleted. Provision of the SSN is mandatory. HUD uses it as

a unique identifier for safeguarding LOCCS from unauthorized access. Failure to provide the information requested may delay the processing of your approval

for access to LOCCS. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.

Retain this form in your records for audit purposes

form HUD-40102-B

(7/94)

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