Service Unit Name
Service Unit #
Troop #
ACH Electronic Debit/Credit Authorization
(This form replaces the bank account information card.)
This form is to be completed by all GSWPA Service Units/Troops/Groups that have been given permission
to open a bank account in the Council’s name. This must be completed as soon as a new bank account
is opened. Once completed, all forms are to be mailed to: GSWPA, 30 Isabella St., Suite 107, Pittsburgh,
PA 15212 Attn: Tina Allman. The information below will be compiled and shared with service unit finance
managers and membership staff.
The undersigned acknowledges and agrees:
1. To be responsible for depositing sufficient funds to cover debits for any Product Sales and will be responsible
for any resulting non-sufficient funds (NSF) charges.
2. To expressly authorize GSWPA to repeat any debit for Product Sales that fails for any reason.
3. To work closely with GSWPA to pay all Product Sales amounts due to council in any manner agreed to by both parties.
4. To authorize GSWPA to credit funds to account for refunds related to deposits, bonuses, etc.
5. This authority will remain in full force and effect until GSWPA has received written notification of the
closing of this bank account and in such time and manner as to afford GSWPA and the Depository a
reasonable opportunity to act upon it.
This authorization must be signed by an authorized check signer on the bank account. List all
authorized signers.
Signature Date
Printed Name Position
Address
City , PA
Zip code
Telephone Email
Authorized Signers: (Please use reverse side for any additional Authorized Signers.)
Name
Name
Address
Address
City
City
Phone
, PA Zip Code
E-mail
Phone
, PA Zip Code
E-mail
Bank Information:
Bank Name
Branch Office
Address
City , PA Zip Code
Routing # Account #
Is there a debit card used with this account?
Yes
No
Who keeps the debit card?
Staple voided check here (not deposit slip).
If voided check is not available, the bank must provide the routing number and troop
167
account number on bank letterhead.
Rev. 6/3/2014