Form Hud-50080-Cb/cr - Resident Opportunities And Self Sufficiency (Ross) Program 2010

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

U.S. Department of Housing

LOCCS / VRS

and Urban Development

RESIDENT OPPORTUNITIES

Office of Public and Indian Housing

AND SELF SUFFICIENCY

(ROSS) PROGRAM

Payment Voucher (All Grantees)

Capacity Building/Conflict Resolution

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

thisinformation, 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 drawdown

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 1937, 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/yyyy)

1 = Partial Disbursement

090

ROSS

2 = Final Disbursement

from:

to:

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

6. Grantee Organization's Name

7. Payee Organization's Name

8. Grant or Project No.

6a. Grantee Organization's TIN

7a. Payee Organization's TIN

Line Item No.

Type of Funds Requested

Amount (dollars)

(cents)

CAPACITY BUILDING

3000

Capacity Building Activities

3010

Training

3011

Consultants

3012

Other

9100

Travel Costs

9400

Administrative Costs

CONFLICT RESOLUTION

4000

Mediation Activities

4010

Establishment of Violence Free Zones (Violence Free Zones)

4011

Youth Services Activities

4012

Resident/PHA Issues

4013

Development of Materials

4014

Training for Mediation/Reconciliation (Mediation/Reconciliation Trng)

4015

Technical Assistance to RAs (RA T/A)

9100

Travel Costs

9400

Administrative 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 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.

form HUD-50080-CB/CR (11/2001)