ILLUSTRATION B - Designation for Automated Clearing House Payment of Compliance Annual Fees

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

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: _________________________________________________________________

Notes

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

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