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Affidavit For Electronic Direct Deposit Form. This is a Illinois form and can be use in Cook Local County.
Tags: Affidavit For Electronic Direct Deposit, 337.009, Illinois Local County, Cook
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Affidavit for Electronic Direct Deposit
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(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.