Bank Account Information and ACH Authorization

Your Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Reason for Submitting*

New AccountChange of Bank or Account NumberChange of Account SignersNo Change: Updating Online Records Only

Type of Account*

TroopService UnitDay Camp

Service Unit*

Troop Number*

Day Camp*

Please attach a voided check (not a deposit slip). If a voided check is not available, the bank must provide the routing number and troop account number on bank letterhead.*

Bank Name and Branch*

NameBranch

Bank Name

Branch

Bank Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is there a debit card for the account?*

YesNo

Name of Debit Card Holder*

First NameLast Name

Last 4 Digits of Debit Card*

Bank Routing Number*

Bank Account Number*

Authorized Signers

Troops: two signers from the troop, one signer from the service unit required
Troops who started before 2021 and who have not updated their bank account: two signers from the troop, one signer from the service unit recommended
Service Units: two signers
Day Camps: two signers

1. Full Name* Phone Number* Email*

2. Full Name* Phone Number* Email*

3. Full Name Phone Number Email

ACH Electronic Debit/Credit (Sweep) Authorization

The authorized signers acknowledge and agree:

1. To be responsible for depositing sufficient funds to cover debits for any product sales and will be responsible for any resulting non-sufficient funds (NSF) charges.

2. To expressly authorize Girl Scouts Western Pennsylvania to reprocess any debits for product sales that fail for any reason.

3. To authorize Girl Scouts Western Pennsylvania to credit funds to the accounts for refunds related to deposits, bonuses, etc.

4. This authority will remain in full force and effect until Girl Scouts Western Pennsylvania has received written notification of the closing of this bank account and in such time and manner as to afford the council and the depository a reasonable opportunity to act upon it.

This authorization must be signed by an authorized check signer on the bank account.

By typing and signing your name below, you are providing your electronic signature and agree to the ACH Electronic Debit/Credit (Sweep) Authorization for the above-listed bank account.

Name*

First NameLast Name

Signature*

You will receive a confirmation of this report. Would you like all signers to receive a confirmation?

YesNo

Second Signer*

example@example.com

Third Signer

example@example.com