Attachment H: Sample Comptroller Check (pdf)

Sample Comptroller Check with Letters for description purposes.

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.