Ach Debit Authorization Form - 2015-2016 printable pdf download

Girl Scouts, Hornets’ Nest Council

7007 Idlewild Road, Charlotte, NC 28212

704-731-6500, Outside Mecklenburg 800-868-0528

Website:

ACH DEBIT AUTHORIZATION – 2015-2016 PRODUCT PROGRAMS

ATTACH VOID TROOP CHECK HERE

(or statement from bank containing account number and bank routing number)

This form is to be used by all GSHNC Troops to authorize ACH debit transactions during the 2015-2016 GSHNC

Product Programs. If your troop turns in this ACH form during the Fall Product Program,

they will not need to resubmit an ACH form for the Cookie Program

TROOP ACKNOWLEDGES AND AGREES TO :

All Product Programs

1. GSHNC will debit the above troop bank account according to the instructions provided during training for the 2015-16 Product

Programs of Fall Product and Cookie Programs.

2. Troop is responsible to deposit sufficient funds to cover these three debits and will be responsible for any resulting NSF

(insufficient funds) charges imposed by the bank.

3. Troop expressly authorizes GSHNC to repeat any debit that fails for any reason.

4. Troop agrees to work closely with GSHNC to pay all amounts due to Council in any manner agreed to by both parties.

Fall Product Program:

5. 100% of the “monies due to Council” per the Bank Deposit tab of Nute for the 2015 Fall Product must be deposited in

troop bank account by 5:00 PM on October, 22, 2015 (to be debited by GSHNC shortly thereafter).

Cookie Program:

6. 30% of the “Amount You Owe Council’ per the Troop Sales Report tab in eBuude on February 5, 2016 must be deposited

in troop bank account by 5:00 PM on February 23, 2016 (to be debited by GSHNC shortly thereafter).

7. Failure to deposit funds to cover initial payment may restrict the ability for your troop to get additional cookies.

8. The final Cookie balance must be deposited in troop bank account on March 11, 2016 by 5:00 PM (to be debited by GSHNC

shortly thereafter).

Troop #: ____________ Service Unit: _______________________________

Print names of persons authorized to sign:

Position:

Signer in charge of the majority of the finances:

This authorization must be signed by an authorized check signer for the troop.

Signature: ___________________________________________________

Date: _______________________________

Printed Name: _____________________________________________________________________________________

Address: ___________________________________ City: ___________________ State: _____ Zip Code: ___________

Telephone: (Day) ___________________________________________________________________________________

Ach Debit Authorization Form - 2015-2016