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