Form MO780-1998 "Non-profit Scrap Tire Cleanup and Disposal Invoice" - Missouri

What Is Form MO780-1998?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2011;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-1998 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

ADVERTISEMENT
ADVERTISEMENT

Download Form MO780-1998 "Non-profit Scrap Tire Cleanup and Disposal Invoice" - Missouri

Download PDF

Fill PDF online

Rate (4.6 / 5) 55 votes
Page background image
MISSOURI DEPARTMENT OF NATURAL RESOURCES
SOLID WASTE MANAGEMENT PROGRAM
NON-PROFIT SCRAP TIRE CLEANUP AND DISPOSAL INVOICE
PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
In order for this invoice to be processed in a timely manner, you must provide a copy of the cancelled check (front and back) for the
cost of proper disposal of the tires and the original receipt from the tire hauler, tire dealer or other legal destination.
The cancelled check must be from the entity that applied for reimbursement. Governmental and for-profit entities are not eligible for
disposal cost reimbursement.
Attach an original receipt showing proof of delivery to a legal recycler, end-user, processor or landfill. The receipt must indicate the
number of tires delivered, cost involved and must indicate paid-in-full. The receipt needs to be signed by a representative of the
group seeking reimbursement and by the recipient of the tires.
Make sure you have a current vendor input number issued by the State of Missouri Office of Administration. This can be accessed
through the online Vendor Services Portal at www.vendorservices.mo.gov/vendorservices/Portal/Default.aspx.
NON-PROFIT ORGANIZATION
ORGANIZATION NAME
ADDRESS (CITY, STATE, ZIP CODE)
CONTACT PERSON
TITLE
TELEPHONE WITH AREA CODE
FAX
E-MAIL
FEDERAL TAX ID
PROJECT NUMBER (FROM APPROVED APPLICATION)
DESCRIPTION
NUMBER OF TIRES
DISPOSAL COST
AMOUNT REQUESTED
COLLECTED
Reimbursement of cost for proper
$
$
disposal of scrap tires collected as a
result of a charitable, fraternal or other
non-profit organization’s voluntary
cleanup of land and water resources
authorized in Section 260.276.3, RSMo.
DECLARATION AND SIGNATURE
I certify that (#)
scrap tires collected during this cleanup came from Missouri.
I certify to the best of my knowledge and belief the above date is correct and that reimbursement is due and
has not been previously requested.
AUTHORIZED SIGNATURE
TITLE
DATE
DO NOT MAKE ENTRIES BELOW THIS LINE. THIS PART TO BE COMPLETED BY THE MISSOURI DEPARTMENT OF
NATURAL RESOURCES
:
THIS INVOICE IS APPROVED FOR PAYMENT
Yes
No
SIGNATURE
DATE
AMOUNT DUE
$
:
MAIL OR FAX COMPLETED FORM TO
Missouri Department of Natural Resources
Solid Waste Management Program
Scrap Tires and Illegal Dumping Unit
P.O. Box 176
Jefferson City, MO 65102
573-751-5401, Fax 573-526-3902
MO 780-1998 (02-11)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
SOLID WASTE MANAGEMENT PROGRAM
NON-PROFIT SCRAP TIRE CLEANUP AND DISPOSAL INVOICE
PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
In order for this invoice to be processed in a timely manner, you must provide a copy of the cancelled check (front and back) for the
cost of proper disposal of the tires and the original receipt from the tire hauler, tire dealer or other legal destination.
The cancelled check must be from the entity that applied for reimbursement. Governmental and for-profit entities are not eligible for
disposal cost reimbursement.
Attach an original receipt showing proof of delivery to a legal recycler, end-user, processor or landfill. The receipt must indicate the
number of tires delivered, cost involved and must indicate paid-in-full. The receipt needs to be signed by a representative of the
group seeking reimbursement and by the recipient of the tires.
Make sure you have a current vendor input number issued by the State of Missouri Office of Administration. This can be accessed
through the online Vendor Services Portal at www.vendorservices.mo.gov/vendorservices/Portal/Default.aspx.
NON-PROFIT ORGANIZATION
ORGANIZATION NAME
ADDRESS (CITY, STATE, ZIP CODE)
CONTACT PERSON
TITLE
TELEPHONE WITH AREA CODE
FAX
E-MAIL
FEDERAL TAX ID
PROJECT NUMBER (FROM APPROVED APPLICATION)
DESCRIPTION
NUMBER OF TIRES
DISPOSAL COST
AMOUNT REQUESTED
COLLECTED
Reimbursement of cost for proper
$
$
disposal of scrap tires collected as a
result of a charitable, fraternal or other
non-profit organization’s voluntary
cleanup of land and water resources
authorized in Section 260.276.3, RSMo.
DECLARATION AND SIGNATURE
I certify that (#)
scrap tires collected during this cleanup came from Missouri.
I certify to the best of my knowledge and belief the above date is correct and that reimbursement is due and
has not been previously requested.
AUTHORIZED SIGNATURE
TITLE
DATE
DO NOT MAKE ENTRIES BELOW THIS LINE. THIS PART TO BE COMPLETED BY THE MISSOURI DEPARTMENT OF
NATURAL RESOURCES
:
THIS INVOICE IS APPROVED FOR PAYMENT
Yes
No
SIGNATURE
DATE
AMOUNT DUE
$
:
MAIL OR FAX COMPLETED FORM TO
Missouri Department of Natural Resources
Solid Waste Management Program
Scrap Tires and Illegal Dumping Unit
P.O. Box 176
Jefferson City, MO 65102
573-751-5401, Fax 573-526-3902
MO 780-1998 (02-11)