Attachment H: Sample Comptroller Check (pdf)
Daniel W. Hynes
Comptroller - State of Illinois
Section A (Top Left)
Doe Jane Marie
1234 East Street
AnytownUSA, IL 62005
Vendor Number ********* B
Section B (Center Top)
Agency #: Human Services
Warrent Nubmer: AF4302454
Warrent Amount: $616.35
Warrent Date: 06-01-2005
Voucher Number: PV44459333364
Section C (Top Box)
Payment Description: Part C Early Intervention Medical Services to Provider
Not Subject to Contractual Withholdings
Service Dates: 04/08/05-04/26/05
Department of Human Services 1300
Section D (Middle of page alternating shading)
| Invoice Number |
Inv. Date |
Customer ID |
Billing Account Number |
Net Amount |
| 90333364 |
052505 |
|
|
616.35 |
Payment of intrerest may be available if the State fails to comply with the Illinois Prompt Payment Act (80 ILCS 540/1)
* for questions, contact: HUMAN SERVICES 800-843-6154 / 800-447-6404 (TTY)
Section E
Check filled out with the information in the above sections in the appropriate check location. Signed by the current Treasurer and the Current Comptroller.
