Form Hud - 40099 - Idis Access Request - Tcap Only

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OMB No. 2506-0181
(exp. 10/31/09)
IDIS Access Request – TCAP ONLY
Privacy Act Statement: Public Law 97-255, Financial Integrity Act, 31 U.S.C.
This form is to be completed by the recipient’s (or grantee’s)
3512, authorizes the Department of Housing and Urban Development (HUD) to
chief executive officer or designated representative. Send
collect all the information which will be used by HUD to protect disbursement
notarized original to the Office of Affordable Housing
data from fraudulent actions. The purpose of the data is to safeguard the
Programs.
Integrated Disbursement and Information System (IDIS) from unauthorized
access. The data are used to ensure that individuals who no longer require
Public reporting burden for this collection of information is estimated to
access to IDIS have their access capability promptly deleted. This information
average .25 hours. This includes the time for collecting, reviewing, and
will not be otherwise disclosed or released outside of HUD, except as permitted
reporting the data. The information is being collected for IDIS and will be
or required by law. Failure to provide the information requested on the form
used for IDIS access. Response to this request for information is
may delay the processing of your approval for access to IDIS.
required in order to receive the benefits to be derived. 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.
Action
New Request
Renew Lapsed ID
Drop From IDIS
Information
Authorized User’s Name (Last, First, MI):
E-mail Address:
Social Security Number (SSN):
Office Phone:
Office Address:
UOG Code:
Grantee Organization’s Name:
Please Mark All Necessary Authorized Functions:
Set Up Activity
Request Drawdown
Approve Drawdown
Note: Every IDIS user can view activities and generate reports even if no functions are authorized.
Authorization
Authorized User’s Signature
Date
HHQ Approval (OAHP
Date
Director or Designee)
(Note: You can’t authorize yourself, only your CEO or
Notary (signature and date)
“grant holder” can.)
I authorize the person above to access IDIS,
with the functions checked.
Approved by:
Name:
Title:
Office Address:
Street
City
ST
ZIP
Office Phone:
Approving Official’s Signature
Date
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)
Page 1 of 1
form HUD - 40099

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