Fillable STATE OF ILLINOIS COMPTROLLER SUSANA A. MENDOZA Additional (Administrative Office of the Illinois Courts)

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STATE OF ILLINOIS COMPTROLLER SUSANA A. MENDOZA Additional (Administrative Office of the Illinois Courts)

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STATE
OF
ILLINOIS
COMPTROLLER
SUSANA
A.
MENDOZA
Additional Documentation Requested by the Office of the Comptroller
Removal of Personal Information for Judicial Family Members
Pursuant to the Judicial Privacy Act (PA 97-0847)
Judges Name: FAX Number:
EMAIL:
Type of Judgeship:
Supreme Court Justice:
Appellate Court Judge District:
Circuit Judge Circuit:
Associate Judge Circuit:
Relationship to the
Judge (Child under age
Is He/She a
18, spouse parent,
State of Illinois
Social Security
blood relative living
Employee?
Number
at the same address)
Name of Individual
Judges Signature Date
Please Return The Completed Form To:
Legal Department
Office of the Comptroller
325 West Adams Street
Springfield, Illinois 62704
Forms may be faxed to 217.558.5123
or
Sent via E-Mail to: whitney.rosen@illinoiscomptroller.gov
Please note that this form should not be submitted to the Administrative Office Of The Illinois Courts.
4/2017
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STATE OF ILLINOIS COMPTROLLER SUSANA A. MENDOZA Additional (Administrative Office of the Illinois Courts)

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Completed 20 July 2020

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