Form Hud-40202 - Youthbuild Implementation Grant Request Voucher For Grant Payment

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U.S. Department of Housing

OMB Approval No. 2506-0142

LOCCS/VRS

(exp. 09/30/2003)

and Urban Development

Youthbuild Implementation Grant

Office of Community Planning

and Development

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

051

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from:

to:

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5

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

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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)

2010

Acquisition

2020

Architectural and engineering work

2030

Housing construction and related facilities and costs

2040

Housing rehabilitation and related facilities and costs

2050

Replacement reserves and operating expenses

2060

Legal, relocation, and construction management costs

2070

Outreach and recruitment

2080

Education and job training

2090

Trainee wages, need-based stipends and benefits

2100

Counseling, support services, and development of employment and leadership skills

2110

Staff training and technical assistance

2120

Job placement and follow-up

2130

Administration

2140

Other:

2150

Other:

2160

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 :

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.

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form HUD-40202 (2/94)