Debit Adjustment Request for Product Programs Please complete this form if you need to request an adjustment to your scheduled debit for either the Fall Product Program or Cookie Program. Amount to be adjusted may be no less than 75% of what is due. The balance remaining due after the debit must be available for debit by no later than one month after the debit date (exclusive of any Discrepancy Reports on file).A copy of your most current bank statement or applicable transactions record (including current balance) MUST be attached. For Fall Product Program, include November’s transaction information; for the first Cookie Program debit include February (to date); for final Cookie Program debit, include March (to date). Which Program are you submitting for?* 2021 Fall Product 2022 Cookie Program Date:* MM slash DD slash YYYY Service Unit:*204 Journey Girls - ARC204 Journey Girls - UPL400 Rancho Foothills401 Alhambra/Rosemead402 Bonita403 Claremont404 Anita Oaks/Mission Camellias405 Chino406 Canon Trails/Rio Hondo407 CV/Glendale408 Pomona409 River Trails411 Upland412 La Canada414 Monrovia/Duarte415 Las Caballeras416 Puente Hills418 San Marino419 Glendora420 South Pasadena421 Covina Oaks422 West Covina425 Crown Poppy426 Mountain View427 Campo Verde428 Ontario/Montclair429 Gateway450 Las Colinas501 Compton/Lynwood502 Bellfower/Hollymount503 Belmont504 Lachen505 Holly Hills506 Wilshire Park Village507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo516 East LA517 Southeast518 Center City519 Lawnthornes522 La Brea Heights524 King Harbor526 North Redondo Beach528 Manhattan Beach529 South Bay Four533 Marina538 Palisades/Malibu540 San Pedro542 Santa Monica Bay543 South Torrance545 North Torrance546 PV/Peninsula601 Burbank604 Westside605 Rancho Calabasas606 Las Virgenes608 Palmdale612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Rose641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia647 Lancaster649 Coyote Canyon650 North RiverUnsure or N/ATroop Number:* Troop Leader Name:* First Last Troop Leader Phone:*Troop Leader Email:* Enter Email Confirm Email Troop Product Chair Name:* First Last Troop Product Chair Phone:*Troop Product Chair Email:* Enter Email Confirm Email Service Unit Product Chair Name:* First Last Service Unit Product Chair Phone:*Service Unit Product Chair Email:* Enter Email Confirm Email Total Due to Council:*Requested Adjusted Amount to be Debited:*Balance Remaining:*Date remaining balance can be debited:*The balance remaining due after the debit must be available for debit by no later than one month after the debit date (exclusive of any Discrepancy Reports on file). MM slash DD slash YYYY Attach current bank statement or applicable records (including current balance):*For Fall Product Program, include November's transaction information; for the first Cookie Program debit include February (to date); for final Cookie Program debit, include March (to date). Drop files here or Select files Max. file size: 200 MB. Reason for Request:*If the reason for request includes payment owed by parent, and there are no other funds in the troop's account, has a Discrepancy Report been submitted to the Council Product Program Manager?* Yes No Why have you not submitted a Discrepancy Report?*Provide the Unique ID from the Discrepancy Report eForm:*The unique ID can be found on your Discrepancy Report eForm confirmation email. Amount Owed by Parent(s):* Amount in Troop Bank Account:* Product in troop's inventoryPackages:* Cases:* The undersigned have agreed that the requested adjusted amount will be debited on the scheduled debit date as listed in the applicable Troop Guide, and that the remaining balance due will be debited from the troop's account on the agreed upon date, as noted above. If either debit attempt is returned by the bank for any reason (including, but not limited to, insufficient funds (NSF)), the undersigned agree that any fees incurred by council will be added to the balance due. The undersigned have also agreed that the troop is responsible for funds due to council even if there is a parent debt to the troop.Requested by:Name:* First Last Signature*For the purposes of this eForm, Troop Product Chair or Service Unit Product Chair refers generally to the roles relative to the product program season (Fall Product Program or Cookie Program) for which the debit adjustment request is being made.CAPTCHA
