HomeMy WebLinkAboutAttachment CLOCCS '/RS U.S. Department of Housing OMB Approval No. 2535-0102 (exp. 1/31/1004)
and Urban Development
SNAPS Special Needs Assistance Program Office of Community Planning
Request Voucher for Grant Payment and Deveigpment
See Instructions and Public Reporting Burden Statement on bad* ATTACHMENT C
1. Voucher Number 2. LOCCS Pgrm. Area 13. Period Covered by this Request (dates) 4. Type of Disbursement
SNAP HPAC FPartial OFinal
IHP
5. Voice Response No. (5 digits, hyphen, 5 more 6. Grantee Organization's Name
8. Grant No.
6a. Grantee Organization's TIN
.•. .-.•, •.. ............ �t.v yr , w .cyuca.w
NiKrum t,vunu w nenrear ogld r)
1010 Acquisition
1020 Rehabilitation
1021 New Construction
1022 Substantial Rehabilitation
1023 Moderate Rehabilitation
1030 Operating Cost
1040- Rental Assistance
1050 Supportive Services
1060 I Administrative Cost
1070 Child Care
1080 Employment Assistance
1090 Relocation
1100 Leasing
1110 Repair & Maintenance
1111 Prevention (RH)
1112 Capacity Building (RH)
1120 Other:
10. Voucher Total
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
Waming: HUD will prosecute false claims andstatements. Conviction may result in criminal and/or civil penalties. (18 U.S.C.1001,1010,1012; 31 U.S.C. 3729, 3802)
11. Name a Phone Number (including area code) of the Authorized 12. Signature 13. Date of Request
Person who called SNAPS System VRS
Ix
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 Housing and Community Development Act of 1987, 42 U.S.C. 3543, authorizes HU D to collect the SSN. The data are used to ensure that individuals
who no longer require access to Line of Credit Control System (LOCCS) have their access capability promptly deleted. Provision of the SSN is mandatory.
HUD uses it asa unique identifierfor safeguarding LOCCS from unauthorized access. Failure to providethe information requested may delay the processing
of your approval for access to LOCCS. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.
Retain this form in your records for audit purposes page 1 of 2 form HUD -27053-A (2/95)
ATTACHMENT C (CONTINUED)
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. 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.
This information collection is to request payment of grant funds orto designate the appropriate officials who can have access to HUD voice activated payment
system. The HUD voice activated payment system has been especially designed to help the recipient when calling in for a request of funds and improves
the payment process so the recipient will know right away whether their request wig be paid or not. This information collection is required under 24 CFA
Subpart C. 65.21 - Post Award Requirements, the information coliection is needed in order to obtain or retain a benefit.
Instructions for the Request Voucher for Grant Payment for the Special Needs Assistance Program (SNAPs)
Item 1. Voucher Number: The first 3 digits are the prefix to your
program. Enter W' if grant funds are being requested
for a grant awarded under a SHDP or SHP (TH. PH,
SAFAH and Renewal) grant. Enter '038' if funds are
being requested for a Housing Opportunity for Persons
with AtDs (HOPWA) competitive grant. Enter '054' if
funds are being requested for an Innovative Housing
Program (IHP) grant. (if you do not know your 3 -digit
program prefix, contact your local Field Office.) The
remaining 6 digits will be assigned by LOCCSNRS during
the telephone call. The entire 9 -digit number will have to
be entered prior to ending the call.
hem 2_ LOCCS Program Area: Circle 'SNAP' (001) for SHDP
and SHP grant ,requests, 'HPAC' (038) for HOPWA
competitive grant requests, and 1HP' (054) for Innova-
tive Homeless Programs.
item 6. Grantee Organization's Name: Enter the name of the
organization requesting funds. it must be the same name
that appears on the Grant Agreement.
Item 6a. Grantee Organization's Tax identification No: Enter
the tax (employer) Identification Number (TIN)_
Item 7. Not applicable.
item 8_ Grant Number: Enter the project number that appears on
the Grant Agreement.
hem 9. Type of Funds Requested: SNAPs grant VRS draw-
downs are directed against specific funding categories
called Budget Line Item (BLIs). LOCCS associates a 4 -
digit number with each line item. Enter the amount
requested in each category(lines 1010 through 1120) and
the total funds requested under item 10, Voucher Total.
Item 3. Eater the period covered by this request. Item 11. Name & phone number (including area code) of the
authorized person who completed the call-in to VRS. The
Item 4. Type of Disbursement: Check 'partial' until the final authorized person is shown on line 3 of form HUD -27054.
request for grant funds is made. hem 12. Signature of the person identified in item 11.
Item 5. Voice Response No: Enter the 10 digit Voice Response
System (VRS) project number which was sent to you by hem 13. Date of this Request: Enter the date of the call-in to mail. Your regular HUD project number will be repeated request funds.
back for verification after the VRS project number is
entered.
Retain this form in your records for audit purposes page 2 of 2 form HUD -27053-A (2/95)