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.
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, fill out the fields below and upload completed W-9. Fillable W-9 form is below.
Bank Name for ACH Transfer
Banking
Savings
Account #
Routing #
Name on Account
Upload W-9
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of
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.
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of
After Photos
*
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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: