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You will need to attach a copy of the returned check and support documentation to this form (see below).

Upon receiving this form, Girl Scouts of Greater Chicago and Northwest Indiana (GCNWI) will review attached documentation. Complete this form in its entirety to expedite reimbursement of bank fees.

Keep a copy for your records.

Troop Information
Your Information

Please answer questions below to the best of your ability.

1. Is this check from a friend, family member, or someone you or a troop parent trust? *
2. Did you have any reason to believe this check would be returned? *
3. Does this check include a complete name, address, phone and driver’s license number? *
4. Did you verify that the information preprinted on the check was current? *
5. Was this check deposited within 7-10 days of receipt? *
6. Did your troop account incur bank fees associated with this returned check? *
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By signing below I am acknowledging; I have completed this Returned Check Fee Reimbursement Request form with true and correct information. I understand all documentation received will be used to attempt collection of bank fees and that I will receive reimbursement for bank fees from the council as stated above.
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