Ill. Admin. Code tit. 50, § 4415.ILLUSTRATION A
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: | |||||||||||||
(Source: Amended at 30 Ill. Reg. 13176, effective July 24, 2006)