AUTOMATED CLEARING HOUSE TRANSACTIONS (ACH)

AUTOMATED CLEARING HOUSE TRANSACTIONS (ACH)
I (we) hereby authorize Girl Scouts of Ohio's Heartland, hereinafter called Girl Scouts of Ohio's Heartland, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my (our) account indicated below and the bank named below, hereinafter called the BANK, to debit and/or credit the same to such account.
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Acceptable documentation: voided check, letter from the bank, screenshot of online banking page - must include the bank name, and account and routing numbers.
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BANK NAME*
BANK BRANCH
BANK CITY*
BANK STATE*
BANK ZIP*
BANK PHONE*
BANK ROUTING NUMBER*
BANK ACCOUNT NUMBER*
This authority is to remain in full force and effect until Girl Scouts of Ohio's Heartland has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Girl Scouts of Ohio's Heartland and THE BANK a reasonable opportunity to act on it.

I (we) understand that it is my (our) responsibility to notify Girl Scouts of Ohio's Heartland if funds will not be available on the specified date, and that if we do not notify Girl Scouts of Ohio's Heartland, it may result in fees being assessed to my (our) account due to insufficient funds.
TROOP NUMBER*
SERVICE UNIT*
DATE*

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Date
PRINTED NAME of first signer (individual filling out the form)*
Email of first signer (Individual filling out the form)*
example@example.com
Click the signature spot below to type or draw the first signer's signature.
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PRINTED NAME of second signer*
Email of second signer*
example@example.com
SECOND SIGNER:

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After the first person fills out the form and signs it, click submit. An email will go to the second signer. The second signer clicks edit at the bottom of the form, signs and clicks submit. We'll take it from there. Thank you.
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AUTOMATED CLEARING HOUSE TRANSACTIONS (ACH)

PLEASE UPLOAD BANK DOCUMENTATION BELOW