Dca Ca-2 - Georgia Department Of Community Affairs Chip Project Drawdown Request Form

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GEORGIA DEPARTMENT OF COMMUNITY AFFAIRS
CHIP PROJECT DRAWDOWN REQUEST FORM
State Recipient/Sub-Recipient Name: _____________________________________________________________________________________
Grant Number: _____________________________
Federal Tax ID#: ________________________________________
Name and telephone number of the person to contact if there are questions: (PRINT)
Names: ____________________________________________________________ Phone: ________________________________________
SETUP INFORMATION
DCA Project Number
: ________________________________________________________
Final Draw
YES
NO
(ie, CH13XATLA-01)
DRAWDOWN INFORMATION
PROJECT ONLY
Homebuyer/Homeowner
DCA Request Number for this Project:__________________________
Name:_________________________________
Homebuyer/Homeowner Name:
Name:___________________________
Activity Type
Amount Allocated
Amount Drawn To Date
Balance Available for
Amount of Drawdown
Balance Remaining after
DPA/Rehab/PDC
Drawdown
Requested
Drawdown
$
$
Total
$
BANK WIRE/EFT INSTRUCTIONS
State Recipient or Sub-Recipient's Bank:
Intermediary Bank (if applicable):
Depository Name: ___________________________________
Depository Name: _____________________________________
ABA#:_____________________________________________
ABA#: ______________________________________________
Account#:__________________________________________
Account#: ___________________________________________
RECIPIENT - I certify that the data above is correct and that this request is in accordance with the terms and conditions of the above referenced
grant. I further acknowledge that any disbursements attempted by DCA that fail to be deposited in the State Recipient or Sub-recipient’s bank
account as a result of inaccurate wiring instructions provided by the State Recipient or Sub-recipient at time of draw will result in a $40 reduction
in the administrative funds paid to the State Recipient or Sub-recipient for the activity and a corresponding reduction in the administrative grant
available to the State Recipient or Sub-recipient.
Authorized Signatures:
2nd Authorized Signatures:
Name:_______________________________________
Name:_______________________________________
Title:________________________________________
Title:________________________________________
Date:________________________________________
Date:________________________________________
FOR DCA USE ONLY
CHIP Program Staff Reviewed:
Approved by Office Director:
__________________________________ Date: __________
________________________________________ Date:___
_______
Approved by CHIP Manager:
Approved by Division Director:
__________________________________ Date: __________
________________________________________ Date:__
________
(If Over $25,000)
IDIS & MITAS CONFIRMATION (DCA ONLY)
Entered By:________________________________________________
HUD IDIS (Project) NUMBER:____________________________
______
HUD IDIS Voucher #:__________________________________
PROJECT TRANSACTION NUMBER:__________
_________________
FOR ACCOUNTING USE ONLY (DCA)
DRAWDOWN APPROVED ON:_______________________
WIRE CONFIRMATION CODE:__________________________________________
WIRED BY:_____________________________________
DATE:__________________________________
APPROVED BY:__________________________________
DCA | CA-2 Form

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