Form HUD- 101 HUD- 101 Request for Labels

IPIA Request for Labels
(order control)

OMB Approval No. 2502-0233
(expires xx/xx/xxxx)

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

The Manufactured Housing Procedural and Enforcement Regulations 24 CFR Chapter XX Part 3282 Section 552 requires manufacturers to report certification
label usage on a monthly basis. The information collected here will be used to report home distribution, collect fees, and reimburse parties as appropriate
under these Regulations . Public repor ting burden for this collection of inf ormation is estimated to a verage 0.5 hours per respo nse including the time f or
reviewing instr uctions, searching e xisting data sources, gather ing and maintaining the data needed, and completing and reviewing the collection of
information. Response to this information collection is mandator y. 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.
Manufacturer’s Name & Address

Factory Name & Address

Manufacturer’s Representative

Phone

Date (mm/dd/yyyy)

Request for Labels
(By IPIA Agency)

We hereby request _________________ certification labels for our on-hand inventory. Currently our inventory is
(Quantity)

________________ certification labels on hand. Based on our current rate of certification labels issued, the on-hand
(Quantity)

inventory will last for approximately________weeks.

Order Processing
(by HUD’s monitoring agent)

Date request received ______________ . The request for certification labels was placed with the label manufacturer
(mm/dd/yyyy)

by _______________________ on ____________________ in the quantity of _____________ certification labels.
(mm/dd/yyyy)

Note: If the quantity ordered is different than requested, it was authorized by ___________________________________.
(name)

This order should be received within the next three weeks.

Confirmation of Receipt
(to be completed by the IPIA)

We have received the quantity of certification labels authorized by HUD’s contracting agent.
If No, contact HUD’s monitoring agent immediately.

Yes _____ No _____.

This order was received on ____________________ and contained:
(mm/dd/yyyy)

Certification labels ______ - ______________ through & including ______ - ________________= ___________ (Quantity)
These labels were entered into this agency’s on-hand inventory on _____________________________________
(mm/dd/yyyy)

by IPIA authorized label administrator __________________________________________.
(signature)

Distribution
Original - HUD’s Contracting Agent
Copies to: IPIA
Manufacturer
Previous editions obsolete

Form HUD-101 (06/09)