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?*
- 2025 Fall Product Program
- 2026 Cookie Program
Date:*
MM slash DD slash YYYY
Service Unit:*
Troop 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

Max. file size: 300 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 inventory
Packages:*
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.
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Debit Adjustment Request for Product Programs