§4415.ILLUSTRATION A. Designation for Fund Transfer for State Pension Fund for Payment of Annual Compliance Fee

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)