Authorization Number : 950-0433
Agency Series No. : 5-04-14
Status : Active
Agency Web Link :
Agency : LOT
Confidential Description :
Division :
Vital Description :
Section :
Record Title : SETTLEMENT AFFIDAVIT
Revision : 0
Record Description : The form is completed by the Regional Office upon contact from Agent Services that a delinquency exists for an agent. The form includes control number issued, agent name, agent number, delinquency type, amount and district number. The White original copy is returned to Agent Reconciliation (with either the check in payment of cancellation notification); please refer to Schedule #3-17-01.