Print Form Affidavit for Electronic Direct Deposit Clear Form (11/07/05) 337*009 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS AFFIDAVIT FOR ELECTRONIC DIRECT DEPOSIT Company Name: CLERK OF THE CIRCUIT COURT OF COOK COUNTY Company Federal Employer Identification Number or Social Security Number Associated with the Bank Account: 36-6006541 I, _______________________________________________ (Print name of person authorized to handle transactions for the account), hereby authorize THE CLERK OF THE CIRCUIT COURT OF COOK COUNTY Accounting Division, hereinafter called the CLERK, to initiate credit entries and, if necessary, debits or adjustments for any credit entries made in error to the account indicated below with proper notification by the CLERK; I also authorize the depository named below, hereinafter called the BANK, to credit and/or debit the same to such account. BANK INFORMATION: ATTORNEY/FIRM INFORMATION: Name on Account: _________________________________ Attorney Code: ______________ Wire Transfer Routing Number: ______________________ Attorney/Firm Name: _______________________________ Account Number: _________________________________ Address: _______________________________________ Bank Address: ___________________________________ City/State/Zip: ____________________________________ City/State/Zip: ___________________________________ Telephone: _____________________________________ Fax: ___________________________________________ Email: ________________________________________ Type of Account (Choose one.) Checking (please attached a voided check) Savings ______________________________________________________________ This authority is to remain in full force and effect until the CLERK has received written notification (i.e., Authorization to Cancel form) from the undersigned of its termination, in such time and manner as to afford the CLERK a reasonable opportunity to act. SIGNATURE AND DATE (SIGN IN FRONT OF A NOTARY) ___________________________________________ Signature Date Subscribed and sworn to before me this: __________ day of __________________, __________ (NOTARY SEAL) Year ___________________________________________ Notary Signature Date My commission expires __________. Year Check here if seal is embossed FOR COMPANY USE ONLY ______ ADD/PUT ONT ________ date entered: (11/07/05) 337*009 B INSTRUCTIONS The Bond Refund Electronic Deposit program is faster, safer and more convenient than standard mail. The affidavit for Electronic Direct Deposit must be completed in full in order to take advantage of this service. Processing of the affidavit will be delayed if it is not submitted with all of the information requested. To avoid any delays, please carefully follow all the instructions for completing the affidavit, listed below: Call your bank for its 9-digit wire transfer routing number. This MAY NOT be the same as the routing number shown on the bottom left-hand corner of your check. The wire transfer routing number is essential for all wire transfers to take place. Record all of your bank’s information under “BANK INFORMATION” located on the left side of the form. Record current business address, daytime telephone number and email address under “ATTORNEY/FIRM INFORMATION” located on the right side of the form. If your account type is checking, please attach a voided check or deposit slip from your checkbook. If you are attaching a temporary check, make sure that the check has the bank’s MICR numbers included on it. Obtain notarization of the affidavit from a notary public. Please do sign or date the affidavit until a notary public is available as a witness. Mail or fax the completed affidavit to: Accounting Division - Bond Refund Department Richard J. Daley Center 50 West Washington, Room 1005 Chicago, Illinois 60602 Fax: (312) 603-7723 If you choose to fax, please do not mail the originals. Your completed affidavit takes three to six (3-6) weeks to be processed and posted on our system. Deposits should reach your bank no later than three (3) working days after they are posted.