OMB Approval No. 2506-0142
LOCCS/VRS
U.S. Department of Housing
and Urban Development
(exp. 09/30/2003)
Youthbuild
Office of Community Planning
and Development
Planning Grant
Request Voucher for Grant Payment
See Public Reporting Burden Statement and Instructions on back
1. Voucher Number :
2. LOCCS Pgrm. Area: 3. Period Covered by this Request: (mm/dd/yy)
4. Type of Disbursement:
Partial
Final
YB
051
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from:
to:
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5. Voice Response No. (5 digits, hyphen, 5 more ) : 6. Grantee Organization's Name :
7.
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8. Grant No:
6a. Grantee Organization's TIN :
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9. Line Item no.
Type of Funds Requested
Amount :
(round to nearest dollar)
1010
Feasibility studies
1020
Establishment of Youthbuild consortium
1030
Site identification
1040
Planning for education, job training, and other services
1050
Youthbuild Implementation Grant application preparation
1060
Preliminary architecture and engineering
1070
Staff training and technical assistance
1080
Establishment of relationships with labor unions and others
1090
Administration
1100
Other:
1110
Other:
1120
Other:
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. Name & Title of Authorized Signatory (type or print clearly) :
of the Person who Completed this Form:
13. Signature:
14. Date of Request :
X
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.
form HUD-40203 (2/94)
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