ILLINOIS

STATE DISBURSEMENT UNIT

P.O. Box 5921

Carol Stream, IL 60197-5921

Customer Service: (877) 225-7077

 

EPPICard™ Cancellation Form

 

 

First Name:

 

 

 

 

 

Last Name:

 

 

 

 

 

Social Security Number:

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

State

 

Zip

 

Phone Number:

 

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

List all the docket numbers to which EPPICard™cancellation will apply:

 

Docket Number

 

Issuing County or FIPS Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I, _____________________________, do not want my child support payments to be paid via EPPICard
MasterCard anymore. I understand that the ILSDU will not  credit any remaining balance in the form of a
check or Direct Deposit. It is my responsibility to clear my balance from this card.

 

 

____________________________________________   __________________________

            Signature (required to validate this request)                                            Date

 

 

Please fax the completed form to (630) 221-2312 or mail to the Illinois State Disbursement Unit at
the address noted above.

 

If you would like to receive notifications from the State Disbursement Unit that there has been a disbursement on your child support case listed above, please complete the requested information below.

Mobile phone number: __________________              Email: ________________________________

    (Standard Text Messaging rates may apply)                                                        (Please print and write clearly)

Preference (Circle One): Text Message     Email Message

If both mobile phone number and email address are provided but no preference is indicated the notification method will default to email.