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

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

1 LOCCS / eLOCCS

RESIDENT OPPORTUNITIES
AND SELF SUFFICIENCY
(ROSS) PROGRAM
Payment Voucher (All Grantees)
Family Self Sufficiency

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 most 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 systems is eLOCCS.
2. LOCCS Pgrm. Area

1. Voucher Number

ROSS

09

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

. Not applicable

6. Grantee Organization's Name

8. Grant or Project No.

6a. Grantee Organization's TIN

9. Line Item No.

1168
1268

1868


4

7 . Payee Organization's Name

7a. Payee Organization's TIN

Type of Funds Requested

Service

1= Partial Disbursement
2 = Final Disbursement

to:

Amount (dollars)

(cents)

Coordinator (Salary + Fringe)

Training Costs
Administrative Costs

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-FSS (09/2017)