Bank Account Confirmation/ACH Form

Bank Account Confirmation / ACH Form

You are required to submit the Bank Account Confirmation / ACH Form after opening a new troop/service unit bank account OR after making updates to an existing troop/service unit bank account. This confirms to council that the account has been opened or updated at the bank. Please complete this form within 10 days of setting up the account or making any changes. ***Any changes made to a troop/service unit bank account must be requested via the Bank Account Authorization Form and approved via the Bank Account Authorization Letter before making them at your bank.***
Please Select the Reason for this Submission:*

Reporting New Bank Account InformationConfirming Bank Account Changes
This Form is Related to a:*

TroopService Unit
Troop #####:*
Troop Meeting City:*
Troop Meeting State:*
Service Unit ###:*
Service Unit Name: *
Contact Information of Person Submitting Form: *

First NameLast Name
Email:*
example@example.com
Phone Number:*

Area CodePhone Number
Name of Financial Institution:*
***Please ensure this is the name of a financial institution (bank) and not the name of the person submitting this form.***
Financial Institution Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Financial Institution Phone Number:*

Area CodePhone Number
Financial Institution Routing Number (9-digits):*
Checking Account Number:*
Please upload a picture of the front of your check below. You will need to take a picture of your check and save it to your computer. Once saved you can browse below to upload the picture from your computer.

Upload a File
***A picture of the front of your check is not required to submit this form. However, approximately 10% of the submissions received are incorrect and having a copy of the check allows GSDH to resolve issues internally.*** Cancelof
Please list ALL authorized signers on your troop/service unit bank account:
Signer 1:*

First NameLast Name
Signer 2:*

First NameLast Name
Signer 3:

First NameLast Name
Signer 4:

First NameLast Name
Signer 5:

First NameLast Name
Terms of Agreement for ACH

I (we) authorize Girl Scouts - Dakota Horizons (GSDH) to initiate electronic debit and credit entries for the purpose of Girl Scouting, and if necessary, electronic entries to correct any erroneous entires. I acknowledge that the origination of ACH transactions to the troop/service unit account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing with GSDH stating that I wish to revoke this authorization. I understand that GSDH requires at least 14 days prior notice in order to cancel this authorization.
By checking "Agree" you agree to the Terms of Agreement for ACH*

Agree
Contact Information for Person to Receive General Finance ACH Notifications:*

First NameLast Name
Email:*
example@example.com
Should be Empty:

Bank Account Confirmation / ACH Form

Please list ALL authorized signers on your troop/service unit bank account: