HUD-301 Request and Payment for Labels

Request and Payment
for Labels

U.S. Department of Housing and Urban Development
Office of Manufactured Housing Programs

OMB Approval No. 2502-0233
expires 04/30/2016

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.
Manufacturer’s Name & Address

Factory Name & Address

Manufacturer’s Representative

Phone

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 $100.00 _______ (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

Certification Labels ____ -

through & including

____

Certification Labels ____ -

-

=

(Quantity)

____ -

=

(Quantity)

= _____

(Quantity)

____

through & including ____ -

Total Number of Labels Issued __________________ X $100.00 ______ (Fee/Label)* = $ ____
IPIA Authorized Label Administrator

Date
(signature)

(mm/dd/yyyy)

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

* Amount established in 24CFR 3284.5

Form HUD-301 (08/14)