Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete six 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 ______________________________ . 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. Printed by authority of the State of Illinois - March 2005 - 500 - CC-87 American LegalNet, Inc. www.USCourtForms.com STATE OF ___________________________ COUNTY OF ________________________ ) ) ) _________________________________________ Claimant’s Signature _____________________________________ being duly sworn, upon oath deposes and says that he/she is the same person who signed the foregoing complaint, that he/she has read the same and knows the contents thereof, and that the facts therein set forth are true. ________________________________________________ ________________________________________________ Claimant Claimant’s Attorney ________________________________________________ ________________________________________________ City ________________________________________________ OR Street Address Street Address ________________________________________________ State City ________________________________________________ ZIP State ________________________________________________ Telephone Number ZIP Telephone Number Subscribed and sworn to me this ____________________ day of _________________________ 20 _____. ______________________________________________ Notary Public Procedures for Filing Lost Warrant Claims Against the State of Illinois 1. Complete the attached Court of Claims complaint form in its entirety, including your Social Security Number or your Federal Employee Identification Number (F.E.I.N.). 2. If you are represented by an attorney, complete the appropriate section of the complaint form so that all correspondence may be directed to the attorney’s office. An attorney is not required in order to file a Lost Warrant Claim. 3. Sign both claimant lines of the complaint form and have the signatures notarized. 5. Collate the original complaint form, along with any itemized bills, invoices or other materials that substantiate your claim. Make five additional copies of the complaint form and attach the supporting documentation to each one of the complaint forms (original plus five 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. Printed by authority of the State of Illinois - March 2005 - 500 - CC-87 American LegalNet, Inc. www.USCourtForms.com