Claim Form - Illinois Dealer Recovery Trust Fund Board Page 2
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4CLAIM FORM
ILLINOIS DEALER RECOVERY TRUST FUND
Please Print Legibly In The Boxes Below.
DO NOT Use Pencil or Red Ink.
PART I
FIRST NAME
LAST NAME or NAME OF BUSINESS
ADDRESS
ADDRESS (CONT’D.)
CITY
STATE
ZIP CODE
DAYTIME TELEPHONE NUMBER
EVENING TELEPHONE NUMBER
EMAIL
ADDRESS
PART II
SELLING DEALER’S NAME
ADDRESS
ZIP CODE
CITY
STATE
TELEPHONE NUMBER
TO YOUR KNOWLEDGE, IS THE DEALER STILL IN BUSINESS?
Yes
No
EXPLAIN:
ATTACHMENT?
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CONTINUED ON NEXT PAGE
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