Installment Agreement Template (State Of Illinois Office Of Secretary Of State)
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1State of Illinois
Office of Secretary of State
Safety Responsibility Section
Springfield, Illinois 62723
Dr. License No.
Accident No.
_____________________
________________
Party Paying Money
INSTALLMENT AGREEMENT
As a result of a motor vehicle accident which occurred at
,lllinois, on
___________________
El
El
19
I do hereby agree to effect a settlement of claims for property damage
personal injuries
or
___
El,
both
suffered by
on the following terms:
agree to pay the sum of
)to
$
or to his/her personal representative at a rate of
or more per
_____________
$
first payment in the amount of
is due
,19____ with subsequent
_______________
payments being due on the
day of every_____________ until the total sum has been
paid in full.
By execution and acceptance of this installment agreement, I agree that the same may be used by the Illinois
Secretary of State in the administration of the Illinois Safety Responsibility Law.
,19
___________________________
______
STATE OF_________________
ss.
____________________________________________________
County of
(Party Paying Money)
________________________
personally appeared before me, a Notary Public
in and for said County, and acknowledged the execution of the above installment agreement.
My commission expires:
(Notary Public)
ACCEPTANCE
I accept the foregoing agreement and upon completion of its terms, I promise to execute and deliver to
______
______________________________________________ a complete and unconditional release from all claims and
causes of action I now or hereafter may have against
El
El
El
on account of property damage
personal injury
or both
resulting from the above referenced acci-
,
,
,
dent.
By execution and acceptance of this installment agreement, I agree that the same may be used by the Illinois
Secretary of State in the administration of the Illinois Safety Responsibility Law.
Dated
,19
___________________________
STATE OF__________________
ss.
___________________________________________________
County of
(Party Receiving Money)
_______________________
personally appeared before me, a Notary Public
in and for said County, and acknowledged the acceptance of the above installment agreement.
My commission expires: _____________________________
(Notary Public)
OSD SR-11.3
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