Draft HUD Form 4734

Control ID/Transaction No:

Refund: LR-     -VR-    -   (Not taxable)

Payment: LR-     -VP-    -  

Prompt Payment Act – Not Applicable

Tax ID No:

     

Issue 1099

Direct Deposit (Refunds/Optional for Wage Restitution):

To:	Bank Name:	     
	Address:	     
	City/State:	     
ACH/Direct Deposit:	ABA Routing No:	     
For Credit To:	Account No.	     
	Payee Account Name:	     

Wage Restitution Check:

Payee Name & Address

     

     

     

Amount of Refund/Payment:

$     

Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment. (Name/Signature)

     

Regional Labor Relations Officer

Date:

     

Evidence of deposit: (HQLR)

Attached

FHA List Page      

Date of last disbursement:      

Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment. (Name/Signature)

     

Authorized Approving Official, Office of Labor Relations

Date: