Annual Financial Report (Multi-Purpose Long Form) - Illinois Comptroller - 2005
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15FY 2005
Please return completed reports to:
Office of the Comptroller
Local Government Division
ANNUAL FINANCIAL REPORT
100 W. Randolph Street, Suite 15-500
Chicago, IL 60601-3252
MULTI-PURPOSE LONG FORM
Unit Name:
County:
Unit Code:
I attest that, to the best of my knowledge, this report represents a complete and accurate statement of the financial position
of the government as of the end of this fiscal year.
Written signature of government official
Date
Print Name: _______________________________________________________ Title: ____________________________
PLEASE CROSS OUT ALL INCORRECT INFORMATION AND PROVIDE CORRECTIONS
STEP 1: ENTER CONTACT INFORMATION
Is the following information correct and complete?
____ Yes ____ No
If the Chief Executive Officer and the Chief Financial Officer are the same person as the Contact Person, please check this box and
skip to Step 2. If not, please do not leave columns B and C blank.
A. Contact person (elected or appointed official
B. Chief Executive Officer (elected or
C. Chief Financial Officer (elected
responsible for filling out this form):
appointed official responsible for the executive
or appointed official responsible for
administration, i.e. mayor, supervisor, or
maintaining the government’s
chairman):
financial records):
First:
Last:
First:
Last:
First:
Last
Title:
Title:
Title:
Add:
Add:
Add:
City:
City:
City:
State:
State:
State
Zip:
Zip:
Zip:
Phone:
Phone:
Phone:
Fax:
Fax:
Fax:
E-mail:
E-mail:
E-mail:
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