HCI Cleanout Form & Invoice
Heartland pays $25 per hour for labor and will reimburse dump fees, if receipt is provided. If cleanout exceeds $100, prior approval is needed. For approvals exceeding $100, email Lisa Boss at cleanup@hci.net.
Name
*
First Name
Last Name
Dealership
*
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Serial #
*
Description of Building Cleanout
*
Total Amount Due
*
ACH Bank Transfer Information
All fields below must be filled out to initiate ACH transfer.
My ACH Information is Already On File:
*
Yes
No. If no information is on file with HCI, Direct Pay Form and W-9 are required for payment. Fillable Direct Pay and W-9 forms are below.
Upload Direct Pay Form
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload W-9
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Direct Pay Form - Use the three dots on the right to save the fillable form.
W-9 Form - Use the three dots on the right to save the fillable form.
Mailed Check
All fields below must be filled out to initiate check admittance.
Payable To:
Address to Receive the Check:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Photos
Please upload before and after photos.
Before Photos
*
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Pictures must be attached before and after the cleanup.
Cancel
of
After Photos
*
Browse Files
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Choose a file
PIctures must be attached before and after the cleanup.
Cancel
of
Upload Dump Invoice (if applicable)
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of
Submit
Should be Empty: