Employee Address Certification
Please submit a copy of this completed form to the State of Illinois Comptroller-Payroll Unit, 325 West Adams Street, Springfield, IL 62704
C-26 (1/2020)
Agency Number
New Employee
Address Change
Name Change Former Name ______________________________________________________
Social Security Number
- -
Date of Birth
/ /
Voting County
Last Name
First Name
Middle Initial
Voting Address
Zip Code
Mailing Address (if different than above)
Zip Code
Foreign State Providence
Foreign Postal Code
Country Code
By signing below, I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge.
Employee Signature _____________________________________________________________ Date / /
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