2025-2026 ACH Debit Authorization

2025-2026 ACH Debit Authorization

(must be completed every Girl Scout year, October-September)
Status

In ProgressCompleted
GIRL SCOUTS OF NASSAU COUNTY, INC.

110 Ring Road West Garden City, NY 11530-3296 T 516-741-2550 ; F 516-741-2207
***NEW PROCESS FOR 2025-2026***

The two troop volunteers named on the bank account MUST BOTH sign the authorization, but submit only ONE ACH form (instead of sending two separate forms, as in prior years). Troop Leader 1 will first fill out the form, including Troop Leader 2's email address. Once submitted, Jotform will automatically email the SAME form/link to Troop Leader 2 to confirm, sign, and complete the submission. Please note the ACH form is not fully submitted until both leaders sign it!

This form is to be used by ALL GSNC troops to authorize ACH transactions during the 2025 Mags&Munchies Program and the 2026 Cookie Program.

To participate in both Mags&Munchies/Cookie Program, complete all parts of this form. Forms received by October 3, 2025 will count toward the criteria for the 2025 Mags&Munchies Troop Bonus. Forms received by January 13, 2026 will count toward the 2026 Girl Scout Cookie Program Troop Proceeds Bonus.

The form and required account verification (bank letter or voided check) MUST be completed and attached. If the Troop changes bank accounts, a new form must also be submitted within 5 business days of the change. If you have any questions, please email customercare@gsnc.org.
TROOP ACKNOWLEDGEMENT AND AGREEMENT
Troop # (troop#)* acknowledges and agrees that:
1. GSNC will debit and/or credit the bank account listed below according to the instructions and dates provided during training and in the Troop Manager's Manuals for the 2025 Mags&Munchies Program and the 2026 Cookie Program.
2. To delay or reduce any scheduled payment, Troop must notify Council in accordance with the procedures set forth on the ACH Adjustment Form.
3. If funds are not available and the ACH adjustment form has not been submitted as per Council procedures, Troop will be responsible for any resulting non-sufficient funds (NSF) charge from their own bank and a GSNC fee of $25.00 per sweep.
4. Troop authorizes GSNC to perform additional sweeps after failed attempts.
5. Troop agrees to follow Troop banking procedures as listed in GSNC Volunteer Essentials.
6. In the event of multiple failed sweeps, Troop agrees to work closely with GSNC to pay all amounts due to Council. If a written agreement cannot be reached in a timely manner, penalties disclosed within GSNC Volunteer Essentials will be enforced.
Bank Account Information (Checking Account Only)
Bank Name:(bank name)*
Branch Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Account Number:(account number)*
Routing Number: (routing number)*
I hereby authorize, Girl Scouts of Nassau County, Inc. to withdraw amounts owed to them by Troop (troop #)*, Service Unit (Service Unit) * , for the Mags&Munchies Program and/or the Girl Scout Cookie Program.
Please attach one of the following account verification:
(choose one)*

Voided Check (no starter check accepted).Bank letter or specification sheet (See your local bank representative) which includes bank letterhead, troop number, FULL account number and routing number.
File Upload*

(upload either a voided check or bank letter)
Cancelof
This authorization must be signed by BOTH Troop Leaders as authorized check signers for the troop. After Troop Leader 1 submits the information below, this form will be automatically emailed to Troop Leader 2 to also review, sign, and complete the full submission.

I understand that I am responsible for all monies collected by me from the Girl Scouts/parents/guardians/troop sales, and that said monies must be deposited in my Troop’s bank account and must be available on the published date of the ACH sweep. In the event of non-payment, I understand that Girl Scouts of Nassau County reserves the right to initiate collection procedures by its designated agent, including civil suit and criminal prosecution on delinquent accounts. I further understand that all costs associated with the above-mentioned collection process, include an additional 30% fee, and any attorney fees incurred, will be my responsibility.
Date*

MonthDayYear
Date
***PLEASE RE-CONFIRM that the email addresses you provide below are accurate prior to clicking "Submit", to ensure this form/link is emailed to the correct recipient.
Troop Leader 1's Full Name*

First NameLast Name
Troop Leader 1's Email*
example@example.com
Troop Leader 2's Full Name*

First NameLast Name
Troop Leader 2's Email*
example@example.com
Troop Leader 1's Electronic Signature: I understand that typing in my name below under 'electronic signature' acts as a binding signature to this form and that I am the person whose name appears on this form.*

First NameLast Name
Troop Leader 1's Signature*

Clear
***PLEASE NOTE: The Signature Field for Leader 2 will not be visible/available in the form until Leader 2 "SIGNS THE FORM" from the email they receive from Jotform.
Troop Leader 2's Electronic Signature: I understand that typing in my name below under 'electronic signature' acts as a binding signature to this form and that I am the person whose name appears on this form.*

First NameLast Name
Troop Leader 2's Signature*

Clear
Should be Empty:

2025-2026 ACH Debit Authorization

GIRL SCOUTS OF NASSAU COUNTY, INC.

TROOP ACKNOWLEDGEMENT AND AGREEMENT

Bank Account Information (Checking Account Only)

Please attach one of the following account verification:

This authorization must be signed by BOTH Troop Leaders as authorized check signers for the troop. After Troop Leader 1 submits the information below, this form will be automatically emailed to Troop Leader 2 to also review, sign, and complete the full submission.