Form Hud-50080-Urp - Loccs / Vrs Hope Vi Program Payment Voucher

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U.S. Department of Housing

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

LOCCS / VRS

and Urban Development

HOPE VI Program

Office of Public and Indian Housing

Payment Voucher

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time to review instructions, search

existing data sources, gather and maintain the data needed, and complete and review 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 uses the Line of Credit Control System/Voice Response System (LOCCS/VRS) to process requests for payments to HOPE VI Grantees. Grant

recipients fill out this voucher form 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 to enter the information and to confirm information that is spoken back by the VRS simulated voice. This information

is required to obtain benefits under the HOPE VI Program. 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

058

URP

2 = Final Disbursement

from:

to:

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

6. Grantee Name

7. Not applicable

8. HOPE VI Grant Number

6a. PHA's TIN

7a. Not applicable

9. Line Item No.

Type of Funds Requested

Amount (dollars)

* (cents)

1408

Management Improvement / Community + Supportive Services

1410

Administration

1430

Fees & Costs

1440

Site Acquisition

1450

Site Improvement

1460

Dwelling Structures

1465

Dwelling Equipment - Non-Expendable

1470

Non-Dwelling Structures

1475

Non-Dwelling Equipment

1485

Demolition

1495

Relocation 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 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.

Previous editions are obsolete

form HUD-50080-URP (03/2001)