Voluntary Disclosure Agreement - Illinois State Treasurer'S Office (Page 2 of 2) in pdf

Voluntary Disclosure Agreement - Illinois State Treasurer'S Office Page 2

Voluntary Disclosure Agreement

7. By executing this Agreement, the undersigned Holder hereby represents and warrants that they will maintain

records enabling them to annually report the names and addresses of individuals for whom they are

required to report unclaimed property. Failure to maintain said records following the execution of this

document renders the Agreement null and void.

8. If any of the representations made by the Holder in this Agreement are false or misleading, this Agreement

becomes null and void and the Treasurer may assess any fees or penalties allowed by the Act and

commence any other action permitted by law. The Treasurer may, at any time during the course of this

Agreement, terminate the Agreement by providing written notice to the Holder.

9. This Agreement shall be effective upon execution by the parties hereto and thereafter shall be binding upon

the Treasurer and the Holder, its successors and assigns.

10. Any modifications or changes made to the Agreement by the Holder will not be accepted by the Treasurer.

11. The persons signing this Agreement certify that they have the power to enter into and execute this

Agreement.

Holder

The Illinois State Treasurer’s Office

Unclaimed Property Division

By: ___________________________________

By: _____________________________

Print Name: ____________________________

Jeff Wininger

Reporting & Technical Review Administrator

Title: __________________________________

Phone: ________________________________

Date: ___________________________

Please return signed Agreement to:

Address and contact to be used for reporting form

Office of the Illinois State Treasurer

Street Address: __________________________

Attn: Jeff Wininger

City, State, Zip: __________________________

Suite 100

Contact: _______________________________

1 West Old State Capitol Plaza

Phone: ________________________________

Springfield, IL 62701

Voluntary Disclosure Agreement - Illinois State Treasurer'S Office Page 2