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Reimbursement Form. This is a Illinois form and can be use in Court Of Claims Secretary Of State.
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Tags: Reimbursement Form, Illinois Secretary Of State, Court Of Claims
Illinois Court of Claims
Office of the Secretary of State
630 S. College St., Springfield, IL 62756
(Complete six copies)
Reimbursement Form
IN THE COURT OF CLAIMS, STATE OF ILLINOIS
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Claimant
vs.
Respondent,
STATE OF ILLINOIS
Claim #: _______________________
Amount Claimed: ________________
Reimbursement
Claimant seeks from Respondent payment in the sum of $ ________________ for reimbursement rendered as stated on the
attached statement and made a part thereof as Exhibit “A.” Claimant requests payment of the sum of $ ________________ ,
and has made demand for same from the Illinois Secretary of State, and such demand was refused.
Claimant further states that no assignment of said claim, or any interest therein, has been made to any person, and that
the Claimant is justly entitled to payment of the same from Respondent after allowing all just credits.
Claimant further states that the Claimant’s Federal Employer Identification Number (F.E.I.N.) is: __________________ ,
or that his/her Social Security Number is: ____________________________ .
STATE OF ___________________________
COUNTY OF ________________________
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_________________________________________
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.
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Claimant
________________________________________________
Street Address
________________________________________________
City
State
________________________________________________
ZIP
Telephone Number
The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 705 ILCS 505/1 et. seq. Disclosure of this information
is REQUIRED. Failure to provide any information will result in this form not being processed
Printed by authority of the State of Illinois - March 2005 - 500 - CC-84
American LegalNet, Inc.
www.USCourtForms.com
Procedures for Filing Reimbursement 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. Sign the Claimant’s signature line of the complaint form. Please print your name in the space that says Claimant.
3. Collate the original complaint form, along with documents 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 Reimbursement Claims.
Printed by authority of the State of Illinois - March 2005 - 500 - CC-84
American LegalNet, Inc.
www.USCourtForms.com
