HILL'S COUPON PAYMENT REQUEST INVOICE
[Pages:1]HILL'S COUPON PAYMENT REQUEST INVOICE
STORE NAME: _____________________________________________________________________
MAILING ADDRESS: ________________________________________________________________
CITY: __________________________ STATE: __________________ ZIP: _________________
SUBMISSION DATE: _______________ HILL'S ACCOUNT NUMBER: ________________________
REQUISITION NUMBER*: ____________________________________________________________ *Please assign a number to this invoice requisitions. That number will appear on your check so you can reconcile payment against this request.
COUPON CODE NUMBER (Above bar code)
COUPON X VALUE
QUANTITY =
TOTAL
Total Coupon Value # coupons x $0.08
Total
ENCLOSE THIS FORM WITH SHIPMENT OF COUPONS AND MAIL TO:
HILL'S COUPON REDEMPTION CENTER CMS Dept. 52742 One Fawcett Drive
Del Rio, TX 78840-9903
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