Outstanding Balance Report Form for Juliette Girl Scouts

Caregiver Contact Information
Caregiver Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the Juliette Mentor is different than the Caregiver, please provide their name below.

Mentor First NameMentor Last Name

Outstanding Balance Details
AMOUNT 1: Amount due to council*
See email from GSMW if you are unsure
AMOUNT 2: Funds paid to council already*
Remaining balance due to council*
Field will automatically calculate the remaining balance due.
How were the funds already paid to council submitted?*
If you chose Other, please explain further.*
Reason for Late Money*
Please clearly explain the reasons for having an outstanding balance.
Please detail out at least one amount and date for paying the outstanding balance.
Payment 1: Amount to Pay*
Estimated Date*

MonthDayYear
Date
Payment 1: Amount to Pay
Estimated Date

MonthDayYear
Date
Acknowledgement*

Financial liability for the outstanding balance detailed above is the responsibility of the Juliette and their Caregiver. By checking this box, I understand that any remaining outstanding funds for this Juliette Girl Scout may impact the eligibility of both the Juliette and the Caregiver's participation in future product programs.
Signature*

Clear
Date*

MonthDayYear
Date

Pickup Receipts Information
Do you have copies of the product pickup receipts available to upload?*
List who you picked up the product from. *
GSMW Staff, Service Unit, Delivery Truck or another Juliette.
Please upload receipts for product received by caregiver from GSMW Staff, Service Unit, another Juliette or Delivery Truck provided during product pickup. For the Cookie Program, please include any receipts for product pick up from the Cookie Cupboard, if applicable.

You should have received a receipt from the person/group you received the product from.
Cancelof
Should be Empty:

Caregiver Contact Information