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
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