P.E.P Tire Disposal ACH Payment | Prairie Band Potawatomi Nation Online Payment

Payment Details

*This information is required

Applicant Name*

First Last

Date*

Phone*

Applicant Address*

Street Address Address Line 2 City State ZIP Code

Applicant Signature*

Reduced Rate Section (Reduced rate guidelines listed ABOVE)

Are You Applying For Reduced Rate?*

Yes
No

Applicant is a PBPN Enrolled Member*

Yes
No

Enrollment #

Tire Disposal Information

*This information is required

Number of Tires to be Disposed*

Price: $2.50

Descriptive Location of Tires for Disposal - Example: East of fence, or end of driveway, be specific as possible*

Billing Details

*This information is required

Email*

Billing Address*

Same as Applicant Address

Street Address Address Line 2 City State ZIP Code

Bank Transfer*

Account holder Name * Account Number * Routing Number * Account Type * Check Type *

PAYMENT TERMS AND CONDITIONS*

AUTHORIZATION
By checking the "I accept the Terms and Conditions" checkbox below I authorize my bank to debit my specified account for the amount of my payment. This is a one-time payment which will occur on the next business day or as soon as practical thereafter. If my payment cannot be completed for any reason, including insufficient funds or error in the information which I submitted, I will retain the same liability, which is my sole responsibility, for payment as though I had not attempted to make the payment. I also understand that additional fees and penalties may be collected to the extent of applicable law.

RECEIPT
A receipt can be printed after payment is accepted which may serve as evidence of payment. If an email address is provided during the payment process, a receipt will be emailed to you after the payment is processed.

CONTACT
If for any reason you wish to make a change to the payment after submission, please contact Prairie Band Potawatomi Nation for assistance at 877.715.6789

I agree to the terms and conditions

Convenience Fee*

Price:

Total

$0.00

CAPTCHA

For Office Use Only

Eligible for Reduced Rate

Yes
No

Date Received

Payment Type

Number of Tires @ $2.50

Date of Removal

Reassessment

Yes
No

Staff Signature

PRAIRIE BAND POTAWATOMI NATION

Tire Disposal ACH Payment

Payment Details

Reduced Rate Section (Reduced rate guidelines listed ABOVE)

Tire Disposal Information

Billing Details

For Office Use Only