2022 - 2023 PRODUCT SALES PROGRAM ACH FORM

Girl Scouts of Connecticut 2022 - 2023

Electronic Payment (ACH) Authorization Form

This form should be completed by an authorized signer on the troop's account.

By providing the requested information below, you authorize GSOFCT to debit your troop's bank account for the total amount due per the terms of agreement. This banking information will be used to initiate payments for all of the 2022-2023 Product Sales Programs. In the event that the troop is due a credit, GSOFCT will use the banking information provided to credit/return any monies due.

* Fields are required for submission.
Name*

First NameLast Name
Service Unit Name*
(Example: Arrigoni, Nutmeg, etc.)
5 Digit Troop Number or - 5 Digit SU Number IF for a SU bank account*
(Service Unit numbers start with 08###)
Position in Troop*

Troop Co-LeaderTroop TreasurerSU TreasurerSU ManagerOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Re-enter 5 Digit Troop/SU Number*
(Service Unit numbers start with 08###)
Does this ACH replace a previous ACH form?*

YESNO
Sorry, the troop #'s do NOT match

Please fix error inorder to continue.

Bank Name*
IE: Webster, TD, ION, People's, etc
Type of Account*

Checking (most common)Savings
Bank Routing Number (see pic for symbols)*
Some starter checks will have the check number to the left of the routing number. Please note that 000091 is not the routing number.
Bank Account Number (see pic for symbols)*
Please take a photo of the front of the check against a flat surface for account verification. (Not required, but helpful in the event of an incorrect account number.)
Re-enter Bank Account Number*
Sorry, the account #'s do NOT match

Please fix error inorder to continue.