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ACH Credit Form
This form is to be submitted for reimbursements for counterfeit bills, bank fees (cash processing/multiple transactions), stolen and unpaid parent money, as related to product programs.
2023 only: request delay ACH payment
This form is being completed due to:
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Bank Fees/Counterfeit
Stolen Money/Product
Unpaid Parent Money
Delay ACH Payment
Select Your Area:
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Redwoods
North Central
North Coast
East Bay/Solano
South Bay/Peninsula
Service Unit Name/Number?
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101- Montgomery Village
102- Rincon Valley
103- Sonoma Valley
104- Redwood Empire
105- West Sonoma
106- Friendly Neighborhood
107- Chalk Hill
108- Petaluma
112- Mendocino
125- Eureka
127- Redwood
128- Eel River
133- Crescent City
142- Lake/Mendocino
201- Benicia
202- Twin Sisters
203- Napa
205- Upper Valley
206- Vacaville
207- Vallejo
301- Berkeley/Albany
302- Cresta Blanca
303- Oakland
305- Chabot
307- Coyote Hills
308- Dos Pueblos
309- Crossroads
310- Alameda
320- Delta Gateway
321- Diablo Shadows
322- Harvest Sands
323- Las Trampas
324- Creekside
326- Lafayette
327- Orinda/Moraga
328- Walnut Creek
329- West Contra Costa
332- San Ramon
342- Richardson Bay
345- Marin Del Centro
346- Mission Bend
347- Novato
362- San Francisco
382- Sister Cities
384- Pacifica/Daly City
387- Crystal Springs
388- Coastside
389- Mid Peninsula
390- Diamond Crest
392- Redwood City
393- South County
601- Palo Alto
602- Evergreen
604- Gilroy
605- Mountain View
608- Los Altos
610- Blossom Hill/Los Gatos
618- Saratoga
623- South San Jose
625- Santa Clara
630- Cupertino
638- Willow Glen
640- Morgan Hill
642- Branham/Almaden
643- North East San Jose
661- Downtown San Jose
671- Sunnyvale
703- South Siskiyou
705- South Shasta
706- Intermountain
707- North Tehama/Corning
708- South Butte
710- Trinity
715- Glenn
717- Greater Oroville
718- Paradise
722- Greater Redding
730- Chico
735- North Siskiyou
Troop #
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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).
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.
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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
Total value of money and/or product stolen ($):
# of items:
Please note the variety breakdown of product stolen:
Attach police report here (if applicable):
Delay ACH Payment
Delay 50% of payment to the week of June 5
Number of unsold packages:
Indicate troop’s unsold packages by variety:
Adventurefuls:
Lemon-Ups:
Trefoils:
Do-Si-Dos:
Samoas:
Tagalongs:
Thin Mints:
Toffee-tasitcs:
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.
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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:
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Title:
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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.
Girl Scouting builds girls of courage, confidence and character that make the world a better place. 2014 Girl Scouts of Northern California