ILLINOIS

STATE DISBURSEMENT UNIT

P.O. Box 5921

Carol Stream, IL 60197-5921

Customer Service: (877) 225-7077

 

NAME CHANGE FORM

 

All name changes are required to have the following information submitted:

A copy of one of the following with the correct name must be faxed to the Illinois State Disbursement Unit:

  • Drivers License
  • Marriage License
  • Social Security Card

 

 

 

OLD NAME

 

NEW NAME

First Name:

 

 

 

M.I.:

 

 

 

Last Name:

 

 

 

 

 

 

 

Social Security Number:

 

Effective Date of Name Change:

 

 

 

List all the docket numbers to which the name change will apply:

 

Docket Number

 

Issuing County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________________________________   ______________________

            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 above address.