Illinois Administrative Code
Title 50 - INSURANCE
Part 4415 - PAYMENT OF ANNUAL COMPLIANCE FEES FOR PENSION FUNDS
ILLUSTRATION B - Designation for Automated Clearing House Payment of Compliance Annual Fees

Universal Citation: 50 IL Admin Code ยง ILLUSTRATION B
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

Depository Name: _______________________________________________________

Account Name: _________________________________________________________

City:________________________________ State ____________ Zip Code __________

Routing Transit Number of Depository Above: __________________________________

Account Number to be Debited: _____________________________________________

Authorized Pension Representative: __________________________________________

Phone Number: __________________________________________________________

Signed: ________________________________________________________________

Dated: _________________________________________________________________

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