ACH Discrepancy Form

Select Your Area: *
Please choose: *
This form is being completed due to: *
Discrepancy forms and attached information 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).

Section A - Decrease ACH Amount Request

Please select the debit to which this request applies:
Fall Sale Program:
Cookie Sale Program:
Please note ACH debits will continue until all amounts due to Council have been collected.

Reason:

Section B - ACH Credit Request

Please select the reason for this request:
Policy Agreement:
Please attach relevant bank documentation below. For returned checks and counterfeit bills, a notification from the bank including the check image or currency amount and associated fee(s) must be uploaded below. For cash deposited/transactional fees, a complete itemized bank statement for the sale month(s) in which the fees were charged must be uploaded below.


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

Check Amount Total $
0.00
Bank Fee Total $
0.00

Section C - Stolen Money/Product


Section D - Unpaid Money

Please note that copies of all of the delinquent individual’s signed sale receipts and Girl/Parent Responsibility Form must be attached to this form in order for the council to process the request and transfer financial responsibility from the troop to the individual.

Delinquent Individual Information

Fall Sale Program:

Cookie Sale Program:

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Published June 27th, 2017

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