GRAIN PAYMENT REQUEST
Grain Solutions Advisor or Office Manager:
Please Select
Valerie Bauer
Dawn Bowling
Peggy Brodman
Diana Bushman
Kayla Cummins
Stacie Dalenberg
Amanda Haakenson
Julia Hicks
Jill Hines
Shelly Knisely
Cindy Knott
Judy Lowe
Matt Lukac
Lori Miller
Mike Myers
Haley Norris
Angie Siefring
Jody Underwood
Unknown
Date:
*
-
Month
-
Day
Year
Date
Customer Name:
*
Account #:
*
Phone Number:
Please enter a valid phone number.
Receive an email receipt of this submission?
Yes
No
Email:
Payment Options:
Recurring Auto-Pay (paid on Tuesday & Friday until otherwise notified)
Recurring Auto-Pay on Full Contract (until otherwise notified)
Pay All Grain excluding DP, Condo, Deferred (one time payment)
Recurring Auto-Pay by Paper Check (paid each Wednesday until otherwise noted)
Specific Payment Request (one time payment)
Deferred Payment (future payment)
Hold Pay (not deferred)
Auto-Payment of all grain delivered, excluding unsold Delayed Price (DP), Condo and Deferred/Hold Settlements. This selection will remain in effect until a new Grain Payment request form has been submitted.
I acknowledge
Auto-Payment of all Full/Filled grain contracts. This selection will remain in effect until a new Grain Payment request form has been submitted.
I acknowledge
A one-time payment for all eligible sold grain. This selection is for those who had not previously selected one of the Auto-Pay options noted above. A new payment request form will need to be completed for any future grain payments.
I acknowledge
Auto-Payment by paper check paid each Wednesday of all grain delivered, excluding unsold Delayed Price (DP), Condo and Deferred/Hold Settlements. This selection will remain in effect until a new Grain Payment request form has been submitted.
I acknowledge
A one-time payment for customers who wish to be paid for specific item(s). This selection is for those who had not previously selected one of the Auto-Pay options noted above. Payments can be requested for specific Contract, Scale Ticket, Bushel or Payment Amount. A new payment request form will need to be completed for any future grain payments.
I acknowledge
A payment option for customers who wish to defer payment for specific item(s) to a future date. Payments can be requested for specific Contract, Scale Ticket, Bushel or Payment Amount. A new payment request form will need to be completed for any future grain payments. Deferred payments are eligible for the deferred payment program.
I acknowledge
A payment option for customers who wish to hold pay for specific item(s) to a future date. Payments can be requested for a specific Contract, Scale Ticket, Bushel or Payment Amount. A new payment request form will need to be completed for any future grain payments. Hold Pay bushels are not eligible for the deferred payment program.
I acknowledge
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Request Another Payment?
Yes
No
Crop:
Please Select
Corn
Soybeans
Wheat
Payment Request:
Please Select
Contract Number
Scale Ticket Number
Bushels
Specific $ Amount
Payment Details:
List your Contract, Ticket Number, Bushels or $ Amount here.
Comments:
Customer Signature:
Date:
-
Month
-
Day
Year
Date
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