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Authorization For License Renewal Payments - Illinois Department Of Financial & Professional Regulation

Illinois Department of Financial & Professional Regulation

Authorization for License Renewal Payments

The undersigned hereby authorizes the Illinois Department of Financial & Professional Regulation

to initiate the Automated Clearinghouse (ACH) debit entries to the account at the Financial Institution

designated below, for the purpose of collecting license renewal fees on behalf of employees/

contractors of the undersigned company. All fees shall be in compliance with the applicable

Illinois Acts and Rules pertaining to the licenses being renewed.

Company Name ___________________________________________________

(Please type or print all information)

Financial Institution Name ___________________________________________

Account Name ____________________________________________________

City________________________________ State _______ Zip______________

Nine Digit Routing Transit Number of Financial Institution _ _ _ _ _ _ _ _ _

Account Number to be Debited _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Please fax a voided check with this form to the number below)

This authorization remains in full force and effect, unless and until amended or terminated with 30 days

written notification to the other party. The undersigned agrees to notify the Illinois Department of Financial &

Professional Regulation, in writing, of any change to the Routing Transit Number or Account Number at

or prior to the submission of a license renewal requested through this license renewal process.

Failure to allow the Illinois Department of Financial & Professional Regulation to debit renewal fees from the

designated deposit account or to ensure that funds, in an amount at least equal to the invoiced amount,

are available to the Illinois Department of Financial & Professional Regulation for direct debit shall be

deemed to constitute nonpayment of the renewal fee(s).

This agreement shall be governed by the rules of the National Automated Clearing House Association

and the applicable Illinois Acts and Rules pertaining to the licenses being renewed

Authorized

Representative __________________________________ Title ____________________________

Address ________________________________________________________________________

City

State

Zip

Approved ________________________________ Date ____________ Phone ________________

(Signature of Authorized Representative)

Please complete and return to:

Illinois Department of Financial & Professional Regulation

320 West Washington St

Springfield, Illinois 62786

Voice: 217-558-4788

Fax Number: 217-524-2470

Authorization For License Renewal Payments - Illinois Department Of Financial & Professional Regulation