HUD-50080 sc Resident Opportunities and Self Sufficiency (ROSS) Progr

U.S. Department of Housing
LOCCS /eLOCCS
and Urban Development
RESIDENT OPPORTUNITIES
Office of Public and Indian Housing
AND SELF SUFFICIENCY
(ROSS) PROGRAM
Payment Voucher (All Grantees)
Service Coordinators for Public Housing

OMB Approval No. 2577-0166 (exp. 01/31/2021)

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.
The Line of Credit Control System (LOCCS) is HUD's primary grant and subsidy disbursement system for the majority of HUD programs. Organizations and
individuals have access to these grants through an Internet version of LOCCS called eLOCCS, where authorized Business Partners can access, manage, and
drawdown grant funds. LOCCS is accessed through the Internet portal, Secure Systems. The combination of the two system is eLOCCS. This information is
required to obtain benefits under the Native American Housing and Self-Determination Act of 1996.
1. Voucher Number

2. LOCCS Pgrm. Area

090

3. Period Covered by this Request (mm/yyyy)

ROSS

from:

1 = Partial Disbursement
2 = Final Disbursement

4.

to:

5. Voice Response No. (5 digits, hyphen, 5 more )

6. Grantee Organization's Name

7. Payee Organization's Name

8. Grant or Project No.

6a. Grantee Organization's TIN

7a. Payee Organization's TIN

9. Line Item No.


Type of Funds Requested

Amount (dollars)

(cents)

Administrative Costs

7UDLQLQJ&RVWV
1168

Service Coordinator (Salary + Fringe)

10. Voucher Total

$

I certify the data reported and funds requested on this voucher are correct and the amount requested is not in excess of immediate disbursement needs
for this program. In the event the funds provided become more than necessary, such excess will be promptly returned, as directed by HUD.

11. Name & Phone Number (including area code)
of the person who completed this form

12. Name & Title of Authorized Signatory (type or print clearly)
13. Signature

14. Date of Request

X
Warning: I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false
statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)
Privacy Statement: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The authority for collecting Personally Identifiable Information (PII) in the Regulatory Consistency
Communication Board (RCCB) Electronic Feedback Form is based in Section 313 of Public Law 112­95. The purpose of the data is to safeguard the Line of Credit Control System (LOCCS) from
unauthorized access. The data are used to ensure that individuals who no longer require access to LOCCS have their access capability promptly deleted. Failure to provide the information requested on
the form may delay the processing of your approval for access to LOCCS.

Previous versions obsolete

form HUD-50080-SC (11/2001)