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Reimbursement Form - Illinois
| Reimbursement Form Form. This is a Illinois form and can be used in Court Of Claims Secretary Of State . |
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Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete six copies) Reimbursement Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) Claim #: _______________________ ) Claimant ) ) vs. ) ) Respondent, ) Amount Claimed: ________________ STATE OF ILLINOIS ) Reimbursement Claimant seeks from Respondent payment in the sum of $ ________________ for reimbursement rendered as stated on the attached statement and made a part thereof as Exhibit A. Claiman t requests payment of the sum of $ ________________ ,and has made demand for same from the Illinois Secretary of State, and s uch demand was refused. Claimant further states that no assignment of said claim, or any interes t therein, has been made to any person, and thatthe Claimant is justly entitled to payment of the same from Respondent a fter 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 ________________________ ) _________________________________________ Claimants Signature _____________________________________ being duly sworn, upon oath depose s and says that he/she is the same person who signed the foregoing complaint, that he/she has read the same and kn ows the contents thereof, and that the facts therein set forth are true. ________________________________________________ Claimant ________________________________________________ Street Address ________________________________________________ City State ________________________________________________ ZIP Telephone Number The 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 of this informationis REQUIRED. Failure to provide any information will result in this form not being processed Printed by authority of the State of Illinois - March 2005 - 500 - CC-84 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Procedures for Filing Reimbursement 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. Sign the Claimant s signature line of the complaint form. Please print your name in the sp ace that says Claimant. 3. Collate the original complaint form, along with documents that substanti ate your claim. Make five additional copies of the complaint form and attach the supporting documentation to each one of th e 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 Reimbursement Claims. Printed by authority of the State of Illinois - March 2005 - 500 - CC-84 American LegalNet, Inc. www.USCourtForms.com
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