Form Hud-50080-Pdev - Payment Voucher - Public Housing Development - Office Of Public And Indian Housing - U.s. Department Of Housing And Urban Development

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LOCCS / VRS

U.S. Department of Housing

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

and Urban Development

Public Housing Development

Office of Public and Indian Housing

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. Send comments

regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Management

Officer, Paperwork Reduction Project (2577-0166), Office of Information Technology, U.S. Department of Housing and Urban Development, Washington, D.C.

20410-3600. 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.

Do not send this form to the above address.

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/yy):

1 = Partial Disbursement

032

PDEV

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)

1406

Operations

1410

Administration

1425

Initial Operating Deficit

1430

Planning (except HUD technical service fee)

1440

Site Acquisition & Expenses

1450

Site Improvements

1475

Non-Dwelling Equipment

1480

Construction Work/Contract Work-In Progress

1485

Demolition

1495

Relocation Costs

1499

Development Used for Mod

1500

FY 94 & Prior Year Grants & Loans

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-PDEV 4/2000