$
5. Sum approved for immediate payment (includes first rental installment)
6. Sum approved for deferred payment (see note to Disbursing Officer below)
$
REMARKS:
DATE
NAME AND TITLE
SIGNATURE
NOTE TO DISBURSING OFFICER:
The deferred payment under Item 6, above, covers a rental supplement to be paid in installments as follows:
$
on
, $
on
, and
$
on
, upon receipt by Disbursing Officer on an annual certification
that the applicant occupies a comparable decent, safe, and sanitary dwelling.
PAYMENT RECORD
DATE PAID
ITEM PAID
AMOUNT CLAIMED
AMOUNT PAID
(Reverse of ENG FORM 4439)
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