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 submit official documentation of their name change.

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

• Driver’s License
• Marriage License

Effective Date of Change: _________________________________________

	OLD NAME	NEW NAME
First Name:
M.I.:
Last Name:

Phone Number:   _________________________________________

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.

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.