HUD 20755 IDIS Online Access Request Form and Instructions

IDIS Access Request

This form is to be completed by the
recipient's (or grantee's) chief executive
officer or designated representative. Send
notarized original to your local HUD
CPD Field Office.
Action

New Request
Renew Lapsed ID
Add Access To Another Grantee

OMB Approval No. 2506-0171 (exp. mm/dd/yyyy)

Privacy Act 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 which will be used by HUD to protect disbursement data from fraudulent
actions. The purpose of the data is to safeguard the Integrated Disbursement and
Information System (IDIS) from unauthorized access. The data are used to ensure that
individuals who no longer require access to IDIS have their access capability promptly
deleted. This information will not be otherwise disclosed or released outside of HUD,
except as permitted or required by law. Failure to provide the information requested on
the form may delay the processing of your approval for access to IDIS.

Drop From IDIS
Change Name/Functions/Grantee

Information

Authorized User’s Name (Last, First, MI):

E-mail Address:

Social Security Number (SSN):

Office Phone:

Office Address:

CPD Use: UOG Code:

Grantee Organization’s Name:

I am with a:
City

Please Mark All Necessary Functions:
Authorized
Set Up Activity
Functions
Approve Drawdown
HOME
Program Areas
CDBG

County

State

Sub Grantee

Request Drawdown
Local IDIS Administrator
ESG
HOPWA

Note: Every IDIS user can view activities and generate reports even if no functions are authorized.

Authorization

Authorized User’s Signature

Date

Field Office Approval (CPD
Director or Designee):

Date

(NOTE: You can't authorize yourself, only your
CEO or "grant holder" can.)
I authorize the person above to access IDIS, with
the functions checked. (Typed please)

Notary (signature and date):

Approved by:

Office Phone:

Office Address:

Name:
Title:
(Street, City, State, Zip)

Approving Official’s Signature

(

)

-

ext.

Date:

* Approval of State Subgrantee Request - CPD State Coordinator or State Official name, signature, and date:

Name:

Signature:

Date:

Public reporting burden for this collection of information is estimated to average 30 minutes. This includes the time for
collecting, reviewing, and reporting the data. The information is being collected to provide access to HUD’s Integrated
Disbursement and Information System and will be used to track program performance. Response to this request for
information is required in order to receive the benefits to be derived. No assurance of confidentiality is provided. 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.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C.
1001, 1010, 1012; 31 U.S.C. 3729, 3802)

form HUD-27055 (5/30/2006)

*