GSGATL Unpaid Parent Account Form

Debtor/Parent Information
Parent/Guardian Responsible for Debt *

First Name Last Name
Debt Submission for: *

Girl Scout Cookie Program Girl Scout Treats & Keeps Program
Total Items Received *
Chocolate/Nuts or Boxes of Girl Scout Cookies
Original Amount Due $ *
Total Payments Made $ *
Remaining Balance $ *
Parent Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent E-mail *
Primary Phone *

Area Code Phone Number
Secondary Phone

Area Code Phone Number
Place of Employment (if known)
Driver's License # and State (if known)

Attempts to Collect
Use log below to enter the dates of communication with the parent regarding payment of the amount due.

Use the additional space provided to provide the details of your collection efforts.

Note: 5 attempts to communicate and recoup the balance due with at least 3 attempts in writing is required.
Letter
Phone Call
Email
Text
Other
Additional Details
Upload all supporting documents below. These documents should include signed Parent Permission & Financial Responsiblity Form, signed receipts for products issued/received, signed receipts for payments made, proof of communication of debt/balance due, etc. (All file types accepted)
Upload files here: *

Review & Submit
Submission Checklist *
The information being submitted to GSGATL is valid and true. All documents provided were acquired through the standard means of participation in the council sponsored product program. *
Signature

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Debtor/Parent Information