Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete four copies) Lost Warrant Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) ) ) ) ) ) ) ) Claimant vs. Respondent, STATE OF ILLINOIS Pursuant to Illinois Revised Statutes, 15 ILCS 405/10.10 and 405/10.16, Claimant seeks from Respondent the sum of $ ________________ for warrant number _________________________________________________ made payable to ____________________________________ , which warrant was ______________________________ . (To original recipient check\voucher) Lost, Mislaid or Destroyed Warrant was previously issued on or about ____________________ , through ___________________________________ Date Department, Board, Commission of the State of Illinois. Claimant is lawfully entitled to the aforementioned amount, having obtained said warrant _________________________________________ . As payee, by negotiation or as heir of payee - Specify Claimant states that on or about _________________ , he/she demanded a replacement warrant be issued by the State Date Comptroller, which demand was refused. A copy of the letter or refusal is attached hereto. Claimant further states that the original warrant was not negotiated to a third party and that the warrant is not in his/her possession; and in the event the warrant comes into his/her possession, he/she will promptly forward same to the Office of the Comptroller. Claimant further states that no assignment of said claim or any part thereof, or any interest therein, has been made to any person, and the claimant is justly entitled to payment of the same from respondent after allowing all just credits. _________________________________________ Claimant's Signature Printed by authority of the State of Illinois - December 2016 - 1 - CC-87.2 American LegalNet, Inc. www.FormsWorkFlow.com ________________________________________________ Claimant ________________________________________________ Claimant's Attorney ________________________________________________ Street Address ________________________________________________ OR Street Address ________________________________________________ City State ________________________________________________ City State ________________________________________________ ZIP Telephone Number ________________________________________________ ZIP Telephone Number ________________________________________________ Email Address ________________________________________________ Email Address 1. Complete the attached Court of Claims complaint form in its entirety. 2. Collate the original complaint form, along with any itemized bills, invoices or other materials that substantiate your claim. Make three additional copies of the complaint form and attach the supporting documentation to each one of the complaint forms (original plus three copies of each document) and mail to: Illinois Court of Claims 630 S. College St. Springfield, IL 62756 No filing fee is required for Lost Warrant Claims. American LegalNet, Inc. www.FormsWorkFlow.com