Fee Exemption Petition Submission

Agency Contact: Direct Deposit Fee Exemption
Office of the Comptroller
325 W. Adams Street
Springfield, IL 62704
DDFeeExemption@IllinoisComptroller.Gov

Pursuant to 15 ILCS 405/9.03(b), all state payments for an employee's payroll or an employee's expense reimbursement must be made through direct deposit. Any state employee requesting an exemption from this direct deposit mandate due to hardship may petition for fee exemption status. You will be notified via e-mail that your fee exemption petition has been approved or denied at a later date.

SECTION 1: CONTACT INFORMATION
Contact Name:
First*:
MI:
Last*:
Address*:
Address Continued
City*:
State*:
Zip*:
-
State Agency (Employer)*:
DayTime Phone*:
E-mail*:
Re-Enter e-mail for verification*:
SECTION 2: TAXPAYER IDENTIFICATION
Taxpayer Identification Number *: 1 
Validate TIN*: No Dashes or Spaces Please  

1A copy of the IOC's Identification protection policy can be found on our website at:
http://www.ioc.state.il.us/index.cfm/resources/general-resources/identity-protection-policy/

SECTION 3: REASON FOR EXEMPTION

(Maximum characters: 255)
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"By submitting this form, you acknowledge that the content is truthful and accurate to the best of your knowledge. You further acknowledge that it is your intent that submission acts as your digital signature in place of your manual signature, and that your digital signature has the same legal effect as your manual signature."