Illinois State Treasurer’s Office
Attn: Warrant Division/Forgery Section
400 West Monroe Street, Suite 401
Springfield, IL 62704-1848
Phone: (217) 782-4117
Fax: (217) 558-4028
AUTHORIZATION FOR DIRECT DEPOSIT OF FORGERY REIMBURSEMENT
If you choose to have your forgery reimbursement deposited into your account, complete this
form, sign and return it with a deposit slip to the address listed above.
_______________________________ PLEASE PRINT
Social Security Number/Tax ID Number
_________________________________________
Payee Name
____________________________________________________________________________________________
Payee Mailing Address (Apt/P.O. Box) City State Zip Code
I, ______________________________, certify the information provided is correct. I authorize
and request the Illinois State Treasurer to direct my payment for crediting in my account
indicated at the financial organization designated below.
_________________________________ ______________ _______________________
Signature of Payee Date Telephone Number
FINANCIAL ORGANIZATION INFORMATION
NOTE: It is recommended that you contact your financial organization to verify your correct
transit routing number. Any errors in routing or account numbers will result in a draft being
issued directly to you.
_________________________________ _________________________________________________
Name of Financial Organization Financial Organization Area Code & Telephone Number
____________________________________________________________________________________________
Branch Address, City, State, Zip Code
_________________________________ _______________________________
Financial Organization Routing Number Payee Account Number
(Found on the left hand side of the Deposit Slip)
You must select one of the following options:
Direct deposit into my CHECKING account
Direct deposit into my SAVINGS account
9/2014
