Reimbursement Form {CC-84}

Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete four copies) Reimbursement Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) ) ) ) ) ) ) ) Claimant vs. Respondent, STATE OF ILLINOIS Claimant seeks from Respondent payment in the sum of $ ________________ for reimbursement rendered as stated on the attached statement and made a part thereof as Exhibit "A." Claimant requests payment of the sum of $ ________________ , and has made demand for same from the Illinois Secretary of State, and such demand was refused. Claimant further states that no assignment of said claim, or any interest therein, has been made to any person, and that the Claimant is justly entitled to payment of the same from Respondent after allowing all just credits. _________________________________________ Claimant's Signature ________________________________________________ Claimant ________________________________________________ Street Address ________________________________________________ City State ________________________________________________ ZIP Telephone Number The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 705 ILCS 505/1 et. seq. Disclosure of this information is REQUIRED. Failure to provide any information will result in this form not being processed Printed by authority of the State of Illinois - December 2016 - 1 - CC-84.2 American LegalNet, Inc. www.FormsWorkFlow.com Procedures for Filing Reimbursement Claims Against the State of Illinois 1. Complete the attached Court of Claims complaint form in its entirety. 2. Sign the Claimant's signature line of the complaint form. Please print your name in the space that says Claimant. 3. Collate the original complaint form, along with documents that substantiate your claim. Make three additional copies of the complaint form and attach the supporting documentation to each one of the complaint forms (original plus three copies of each document) and mail to: Illinois Court of Claims 630 S. College St. Springfield, IL 62756 No filing fee is required for Reimbursement Claims. American LegalNet, Inc. www.FormsWorkFlow.com