Unpaid Funds Collection Assistance Form

Form
Prior to submitting this form you must complete three collection attempts, one of which must be in writing. Please document your attempts and be prepared to share notes on this form.
Name of person completing form

First NameLast Name
Email of person completing form
example@example.com

Unpaid funds information
Program*

Cookie ProgramMags & Munchies Program
Responsible Party

Parent/caregiverTroop Cookie ManagerTroop Leader/co-leader
Name of Responsible Party*

First NameLast Name
Girl's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Original amount due *
Payments made to date*
Type "0" if none
Total amount due*
I received a copy of the online product permission form for this Girl Scout*

YesNo
Attach copies of signed product receipts or screen shots of online payments made by responsible party*

Cancelof
1st communication attempt*
2nd communication attempt*
3rd communication attempt*
Copy of written communication collection attempt*

Screenshot of email/text/etc
Cancelof
Should be Empty:

Form