Payment Voucher Template printable pdf download

Payment Voucher Template

Payment Voucher

U.S. Department of Housing

OMB Approval No. 2506-0080

(exp. 1/31/2004)

and Urban Development

Rental Rehabilitation Program

Office of Community Planning

Cash and Management Information (C/MI) System

and Development

See Public Reporting Burden Statement on back

An original and four (4) copies are to be completed by the Grantee or Local Recipient and distributed as follows:

Original Send to HUD's Rental Rehabilitation Program, L'Enfant Plaza Station, P.O. Box 23997, Washington, D.C. 20026

Copy 1 retained by Grantee

Copy 3 to State if local recipient is completing form

Copy 2 to Property Owner

Copy 4 to Payee

1. Project Number (assigned at setup)

Project Owner's Name

2. Grantee / Local Recipient Number

Project Address

3. Voucher Number

Last two digits of current calendar year

4. Amount Requested

Check Number (for Grantee / Local Recipient only)

5. Type of Payment (check ” one)

Name and Title of Authorized Signatory (type or print clearly)

Progress

Final

Administrative (project no., project

Signature and Date

owner's name, and project address

should not be filled in.)

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)

form HUD-40021 (2/90)

Payment Voucher Template

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