Illinois > Secretary Of State > Court Of Claims
Lapsed Appropriation Form - Illinois
| Lapsed Appropriation Form Form. This is a Illinois form and can be used in Court Of Claims Secretary Of State . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete six copies) Lapsed Appropriation Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) ) COURT USE ONLY Claimant ) Claim #: _______________________ ) Amount: _______________________ vs. ) ) Respondent, ) STATE OF ILLINOIS ) Claimant seeks from Respondent payment in the sum of $ ________________ for ______________________________ Services or Materialsrendered as stated on the attached statement, and made a part thereof as Exhibit A. Claimant requests payment of the sumof $ ________________ , and has made demand for same from ______________ ________________ of the State of Illinois, Department, Board, Commission and such demand was refused on the grounds that funds appropriated for t he ______________________________________ for such payments have lapsed. Claimant further states that no assignment of said claim, or any interes t therein, has been made to any person, and thatClaimant is justly entitled to payment of the same from respondent after allowing all just credits. Claimant further states that the Claimants Federal Employer Identification Number (F.E.I.N.) is: __________________ , or that his/her Social Security Number is: ____________________________ . STATE OF ___________________________ ) ) COUNTY OF ________________________ ) _________________________________________ Claimant ______________________________ being duly sworn, upon oath deposes and s ays that he/she is the same person who signed theforegoing complaint, that he/she has read the same and knows the content s thereof, and that the facts therein set forth are true.________________________________________________ ________________________________________________ Claimant Claimants Attorney ________________________________________________ ________________________________________________ Street Address Street Address OR ________________________________________________ ________________________________________________ City State City State________________________________________________ ________________________________________________ ZIP Telephone Number ZIP Telephone NumberThe state agency is requesting disclosure of information that is necessa ry to accomplish the statutory purpose as outlined under 705 ILCS 505/1 et. seq. Disclosure ofthis information is REQUIRED. Failure to provide any information will re sult in this form not being process Printed by authority of the State of Illinois - March 2005 - 500 - CC-88 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Procedures for Filing Lapsed Appropriation Claims Against the State of Illinois 1. Complete the attached Court of Claims complaint form in its entirety, including your Social Security Number or your Federal Employee Identification Number (F.E.I.N.). 2. If you are represented by an attorney, complete the appropriate section of the complaint form so that all cor respondence may be directed to the attorney s office. An attorney is not required in order to file a Lapsed Appropriation Clai m. 3. Sign both Claimant lines of the complaint form. Please print your name i n the space in between signatures. 5. Collate the original complaint form, along with any itemized bills, invo ices or other materials that substantiate your claim. Make five additional copies of the complaint form and attach the support ing documentation to each one of the complaint forms (original plus five copies of each document) and mail to: Illinois Court of Claims 630 S. College St. Springfield, IL 62756 No filing fee is required for Lapsed Appropriation Claims. Printed by authority of the State of Illinois - March 2005 - 500 - CC-88 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
