Form Hud-301 - Request And Payment For Labels - 2009
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1Request and Payment
U.S. Department of Housing and Urban Development
OMB Approval No. 2502-0233
expires 01/31/2013
Office of Manufactured Housing Programs
for Labels
The Manufactured Housing Procedural and Enforcement Regulations, 24 CFR Part 3282, require manufacturers to report certification label usage on
a monthly basis. The information collected here will be used in conjunction with reporting home distribution, collecting fees, and reimbursing parties
as appropriate under these Regulations. Public reporting burden for this collection of information is estimated to average 0.5 hours 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. Response to this information collection is mandatory. This agency may not collect this information, and you are
not required to complete this form, unless the form displays a currently valid OMB control number.
Factory Name & Address
Manufacturer’s Name & Address
Phone
Manufacturer’s Representative
Date (mm/dd/yyyy)
Manufacturer’s Request
(to be completed by manufacturer)
We hereby request that our IPIA, _____________________________________________________________________,
for the above manufacturing facility issue ________________(quantity) manufactured home certification labels.
Total number of labels requested _________________ X $39.00__________(Fee/Label)* = $ _______________________
Credit adjustment (include Form 303 with credit)
– $ ______________________
Check amount
$ ______________________
Check number __________________________ dated ______________
(mm/dd/yyyy)
Checks must be made payable to Department of Housing and Urban Development.
IPIA Assignment of Label Numbers
(to be completed by IPIA)
The following unissued certification label numbers are assigned to the specific facility identified above.
Certification Labels _____ - _____________ through & including _____ - ______________ = ___________ (Quantity)
Certification Labels _____ - _____________ through & including _____ - ______________ = ___________ (Quantity)
Certification Labels _____ - _____________ through & including _____ - ______________ = ___________ (Quantity)
Total Number of Labels Issued ___________________ X $39.00________(Fee/Label)* = $
_____________________________
IPIA Authorized Label Administrator ______________________________________________ Date
________________________
(mm/dd/yyyy)
(signature)
Tender payment through Pay.gov and send copy of form and payment receipt.
Distribution
Original - HUD’s Monitoring Contractor
Copies to: IPIA
Manufacturer
Previous editions obsolete
Form HUD-301 (06/09)
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