50 Ill. Adm. Code 4415.ILLUSTRATION B
B Designation for Automated Clearing House Payment of Compliance Annual Fees
Section 4415
Section 4415.ILLUSTRATION B
Designation for Automated Clearing House Payment of Compliance Annual Fees
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: