Form Hud-27054e - Access Authorization Form - 2017
Download a blank fillable Form Hud-27054e - Access Authorization Form - 2017 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Hud-27054e - Access Authorization Form - 2017 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3OMB Approval No. 2535-0102
(exp. 4/30/2020)
U.S. Department of Housing
eLOCCS
and Urban Development
Access Authorization Form
(exp
See Instructions, Public Burden, and Privacy Act statements before completing this form
This form is to be approved by the recipient’s (or grantee’s) Chief Executive Officer or equivalent. All forms must be sent to your HUD Program Office for
review and approval. Retain a copy. MANDATORY REQUIREMENT: New User, Reinstate User and Change Secure Systems ID must be NOTARIZED.
GRANTEE – Mail form to your grant program officer. PROGRAM OFFICER: Required to mail the completed and certified form to: OCFO, User Support
th
Branch (FYMU) 451 7
Street SW, Room 3114, Washington, DC 20410.
1. Type of Function(s)
2a. Secure Systems ID
2b. New Secure Systems ID
□
□
(mandatory)
(if changing ID)
1
New User
5
Revise Authorizations
□
□
2
Reinstate User
6
Name/Address Change
□
□
3
Terminate User
7
Other ______________________
□
4
Change Secure Systems ID
3. Authorized User’s Name (last, first, mi) Print or Type
Title (mandatory)
Office Telephone Number
(include area code)
Complete Mailing Address
E-Mail Address
4. Authorizations (see next page) are required for New User, Reinstate User and Revise Authorization functions. Attach one
Number of Authorization Pages
or more authorization pages as needed. Record the number of attached pages to the right. Each page should be initialed by
Attached
the Approving Official and HUD Program Office POC.
5. Authorized User’s Signature
Date (mm/dd/yyyy)
I authorize the person identified above to access eLOCCS via HUD’s Secure Systems.
6.LOCCS Approving Official Name (last, first, mi) Print or Type
7. Notary (must be different from user
Title
and approving official) Seal, Signature, and
Date Notarized (mm/dd/yyyy)
E-Mail Address
Secure Systems User ID (mandatory)
Complete Mailing Address
Office Telephone Number
(include area code)
Approving Official’s Signature
Date (mm/dd/yyyy)
Title
8. HUD Program Office Point of Contact’s Name (last, first, mi) Print or Type
Office Telephone Number (include area code)
E-Mail Address
Date (mm/dd/yyyy)
HUD Program Office Point of Contact’s Signature
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)
Previous editions are obsolete.
Page 1 of 2
Form HUD-27054E (4/2017)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal