Form Hud-40099 - Voucher printable pdf download

Form Hud-40099 - Voucher

U.S. Department of Housing

OMB Approval No. 2506-0171

LOCCS/VRS

(exp. 11/30/2001)

and Urban Development

HOME Program Payment Certification

Office of Community Planning

and Development

Voucher

1. Voucher Number

2. LOCCS Pgrm. Area

3. Period Covered by this Request

4. Type of Disbursement

019

HOME

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

6. Participant's Name & Address

8. Grant Number

6a. Participant's Tax ID Number

7a. Payee Organization's TIN

Check Type of

Project Number

Amount of Request

Disbursement

( as assigned by HUD)

(show dollars & cents)

Partial Final

Voucher Total

10.

I hereby certify that all the information stated herein, as well as any information provided in any 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. Signature

13. Date of Request

of the Authorized Person who called

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-40099 (1/93)

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