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ACH Credit Form
This form is to be submitted for troops to edit their product program ACH withdrawal, receive reimbursements for counterfeit bills or bank fees (cash processing/multiple transactions), or report stolen money/product.
Please choose:
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Fall Program
Cookie Program
This form is being completed due to:
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Bank Fees/Counterfeit
Stolen Money/Product
Change ACH Withdrawal Amount
Extend 100% ACH Deadline to April 19th, 2024
Troop #
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How much do you wish to have withdrawn?
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Troop Information
Troop Leader/Product Manager's Name:
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Primary Phone #
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Alternate Phone #
Email address:
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Confirm:
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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).
Change ACH Withdrawal Amount
Troop #
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Amount council is approved to withdraw:
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Choose program:
Fall Program
Cookie Program
Bank Fees/Counterfeit
Troop #
*
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.
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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
Troop #
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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):
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:
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Title:
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Published 6/17, Edited February 20th, 2024
* Please Note: Once you submit this form, you'll have the option to print the form contents on the following page.
Girl Scouting builds girls of courage, confidence and character that make the world a better place. 2014 Girl Scouts of Northern California