Illinois Administrative Code
Title 50 - INSURANCE
Part 4415 - PAYMENT OF ANNUAL COMPLIANCE FEES FOR PENSION FUNDS
ILLUSTRATION A - Designation for Fund Transfer for State Pension Fund for Payment of Annual Compliance Fee

Universal Citation: 50 IL Admin Code ยง ILLUSTRATION A
Current through Register Vol. 48, No. 12, March 22, 2024

Illinois Department of Insurance Public Pension Division

Designation for Automated Clearing House Payment of Annual Compliance Fees

State Pension Fund Name: ________________________________________________

City:________________________ State ________________ Zip Code _____________

Fund Account Number to be Debited: _________________________________________

Fund Account Number to be Credited: _________________________________________

Amount of Transfer: _______________________________________________________

Requested Date of Transfer: ________________________________________________

Statutory Authority: ________________________________________________________

Authorized State Pension Fund Representative: _________________________________

Phone Number: __________________________________________________________

Signed: ________________________________________________________________

Dated: _________________________________________________________________

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