Certificate of Service - Illinois

This fillable "Certificate of Service" is a document issued by the Illinois Department of Labor specifically for Illinois residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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STATE OF
____________ )
)
(Name of State)
)
COUNTY OF____________ )
(Name of County) )
CERTIFICATE OF SERVICE
I ___________________________ , Respondent, affirm, certify or on oath state, that I
(Name)
served notice of all documents intended to be used by Respondent for
purposes of the Illinois Department of Labor investigation for wage claim
________________________ upon Claimant or his/her agents appointed to receive service
(Wage Claim Number)
of process by attaching/enclosing a copy of the documentation and sending by
electronic mail (email) with a “read” confirmation or in an envelope addressed to
_________________________at__________________________________
_______________,
(Name of Claimant)
(Address)
(City)
________
______________having mailed the envelope to be served by
(State)
(Zip Code)
U.S. mail/private courier, with postage/delivery charges prepaid at
(Circle One)
__________________________, _____________, ________, ________ on this__________ of
(Address of Post Office or Courier)
(City)
(State)
(Zip Code)
(Day)
________________ , 20____ prior to 4:30 p.m.
(Month)
(Year)
______________________________
(Signature)
_____________________________________________
(Printed Name)
STATE OF
____________ )
)
(Name of State)
)
COUNTY OF____________ )
(Name of County) )
CERTIFICATE OF SERVICE
I ___________________________ , Respondent, affirm, certify or on oath state, that I
(Name)
served notice of all documents intended to be used by Respondent for
purposes of the Illinois Department of Labor investigation for wage claim
________________________ upon Claimant or his/her agents appointed to receive service
(Wage Claim Number)
of process by attaching/enclosing a copy of the documentation and sending by
electronic mail (email) with a “read” confirmation or in an envelope addressed to
_________________________at__________________________________
_______________,
(Name of Claimant)
(Address)
(City)
________
______________having mailed the envelope to be served by
(State)
(Zip Code)
U.S. mail/private courier, with postage/delivery charges prepaid at
(Circle One)
__________________________, _____________, ________, ________ on this__________ of
(Address of Post Office or Courier)
(City)
(State)
(Zip Code)
(Day)
________________ , 20____ prior to 4:30 p.m.
(Month)
(Year)
______________________________
(Signature)
_____________________________________________
(Printed Name)

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