Form Hud-50080-Fss - Family Self-Sufficiency Program Payment Voucher

U.S. Department of Housing

LOCCS / VRS

OMB Approval No. 2577-0166

(exp. 02/29/2004)

and Urban Development

Family Self-Sufficiency

Office of Public and Indian Housing

Program

Payment Voucher

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 this information, 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 drawdwon 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 l937, 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

FSS

041

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)

2000

FSS Grant - Year 1 Approved Budget

Voucher Total

10.

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 the 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-FSS (4/2000)