GSSNV Membership Dept. Bank Account ACH Authorization Form

Once you have opened or made changes to an approved Girl Scout bank account, please complete the form below within 5 business days. The following form authorizes GSSNV to perform ACH Debit transactions. GSSNV Girl Scout Troops/Groups are not active until this form is received by the GSSNV Membership Support Department. This form is not the GSSNV Product Program ACH Authorization. Troops must complete a new Product Program ACH Authorization annually for each product program the troop wishes to participate in.

Date

mm/dd/yyyy

Troop Number

Service Unit Number

Account Number

Bank Routing Number

Signer One

Signer Two

Position

Acknowledgement

By initialing below, all approved check/bank signers authorize & agree to: 1. Maintain and keep in good standing a Girl Scout Troop/SU account using the GSSNV Council Tax ID Number. 2. Work closely with GSSNV to pay any amounts due to GSSNV in any manner agreed to by both parties. 3. Accept responsibility for depositing funds in Girl Scout Troop/SU bank accounts to cover all debts and will be personally responsible for any resulting non-sufficient funds (NSF) charges. 4. Authorizes GSSNV to repeat e-payments that fail for any reason. 5. All account holders agree to the provisions in this acknowledgement Authorize by initialing here:

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