ILLUSTRATION A - Designation for Fund Transfer for State Pension Fund for Payment of Annual Compliance Fee

Current through Register Vol. 46, No. 15, April 8, 2022

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: _________________________________________________________________

Notes

Recodified from ILLUSTRATION A at 41 Ill. Reg. 4978. Amended at 30 Ill. Reg. 13176, effective July 24, 2006