Parent Past Due Cookie Account Form

Parent Past Due Girl Scout Cookie Account forms with signed receipts must be submitted no later than March 23, 2025. Incomplete forms and those with no receipts will not be accepted. Please use the document upload section of this form to upload receipts and other documentation you need to submit to council.

All fields marked with * are required and must be filled.

Troop Number (must be 5 digits) *

Person Responsible for Payment *

Address *

City *

State/Province *

Postal/Zip Code *

Place of Employment *

Girl Scout's Name

First Name *

Last Name *

Total Number of Packages Sold *

(a) Number of packages sold at $7 *

(b) Total Due *

(d) Balance due from Parent (b-c)

0.00

Documentation

The following must be submitted with this form:

Receipts signed when cookies checked out
Receipts for any money paid by responsible party
Documenation (dates) of communication with responsible person regarding account (examples: write up every date you talked, what was said, etc.)

Please upload all applicable documentation: *

Name of person completing this form

First Name *

Last Name *

Phone Number *

Email Address *

Electronic Signature

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. Please type your full name here: *

Published November 7th, 2023