Bank Account Info and ACH Authorization

Bank Account Info and ACH Authorization
Troop Number*
Service Unit Number
Required Reporting of Bank Account Information

This form must be completed by all GSMISTS Service Units/Troops that have been given permission to open a bank account in the Council's name. This form must be completed for new bank accounts as soon as it is
opened or if there are any changes in authorized signers.

The information below will be available to your Service Unit Treasurer and GSMISTS staff. Upon submission your form will be sent to customercare@gsmists.org.
Reason for Submitting:

New TroopChanged bank of account numberChange of signers
Bank Information
Bank Name*
Branch Office*
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Routing Number*
Account Number*
Is a debit card used with this account?*

YesNo
If yes, who keeps the debit card?
Authorized Signers

(2 required) Please submit a new form if authorized signers change in the future
Authorized Signer 1*

First NameLast Name
Signer 1 Email*
example@example.com
Phone number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Signer 2*

First NameLast Name
Signer 2 Email*
example@example.com
Phone number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Signer 3 (optional)

First NameLast Name
Signer 3 Email
example@example.com
Phone number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 Program and will be responsible for any resulting non-sufficient funds (NSF) charges.
2. To expressly authorize GSMISTS to reprocess any debit for Product Program that fails for any reason.
3. To work closely with GSMISTS to pay all Product Program amounts due to GSMISTS in any manner agreed to by both parties.
4. To authorize GSMISTS to credit funds to the account for refunds related to deposits, incentives, etc.
5. This authority will remain in full force and effect until GSMISTS has received written notification of the closing of this bank account and in such time and manner to afford GSMISTS and the bank a reasonable opportunity to act upon it.
This authorization must be signed by an authorized check signer on the bank account.
Signer's name*
Today's date*
mm/dd/yyyy
Signature*

Clear
Should be Empty:

Bank Account Info and ACH Authorization

Bank Information

Authorized Signers

ACH Electronic Debit/Credit (Sweep) Authorization