ACH Credit Form

This form is to be submitted for troop reimbursements for counterfeit bills, bank fees (cash processing/multiple transactions), stolen and unpaid parent money, as related to product programs.

Please choose: *

Fall Program

Cookie Program

This form is being completed due to: *

Bank Fees/Counterfeit

Stolen Money/Product

Unpaid Parent Money

Select Your Area: *

Service Unit Name/Number? *

Troop # *

Troop Information

Troop Leader/Product Manager's Name: *

Primary Phone # *

Alternate Phone #

Email address: *

Confirm: *

Submissions are subject to verification prior to approval. Any mismanagement of GSNorCal product or money may result in a denial of the request.

Please complete ONLY the relevant section(s).

Bank Fees/Counterfeit

Please select the reason for this request:

Counterfeit bill(s)

Cash deposited/transaction fee(s)

Bank notifications for counterfeit bills must be uploaded below. For cash deposited/transactional fees, itemized bank statement(s) for the program month(s) in which the fees were charged must be uploaded below.

Briefly explain why Electronic Transfer was not used to collect money from parents. *

Attach bank documentation here:

Bank fees will only be processed if submitted within 14 days of the date as noted on the bank documentation.

Stolen Money/Product

Fall Program

Cookie Program

Total value of money and/or product stolen ($):

# of items:

Please note the variety breakdown of product stolen:

Attach police report here (if applicable):

Unpaid Parent Money

Please note that copies of all the delinquent individual’s signed program receipts, complete documentation of attempts to collect, and signed Parent Responsibility Form must be uploaded below in order for GSNorCal to review the request and transfer financial responsibility from the troop to the individual after approval.

Delinquent Individual Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone #

Fall Program:

Fall Program # of items:

Fall Program Amount Due $

Cookie Program:

Cookie Program # of items:

Cookie Program Amount Due $

All troop transactions and girl balance due in product database reconcile with signed receipts. *

I agree

Document your attempts to collect and conversations (including dates) and any additional comments:

0/256 characters

Signed receipts:

Parent Responsibility Form:

Authorization

Electronic Signature By typing my name on this form, I am entering my "electronic signature" (as defined in The California Uniform Electronic Transactions Act 1633.1 - 1633.17) and certifying that I have read, fully understand and accept all terms of this agreement. Submitted By: *

Title: *

Published 6/17, Edited 7/19

* Please Note: Once you submit this form, you'll have the option to print the form contents on the following page.