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: *
Select Your Area: *

Troop Information

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:
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.

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

Stolen Money/Product

Delay ACH Payment

Indicate troop’s unsold packages by variety:

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

Fall Program:

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

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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