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.