Wildfire Assistance Fund Application

"*" indicates required fields

Please use this form to submit a request for reimbursement of monies spent toward helping or re-supplying those troops and Girl Scouts impacted by the January wildfires.

Examples of qualified expenses include, but are not limited to:
— replacement uniforms, badges, or troop supplies
— membership or camp registration fees for impacted girls/adults
— troop expenses to hold donation event

PROPER RECEIPTS ARE REQUIRED.

A single payment will be disbursed to the payee via ACH or paper check. Once approved, ACH disbursements will be processed within 5 business days and within 10 business days for paper checks.

Contact Information

Name*

First Last

Email Address*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Service Unit*

Troop Number(s) Impacted*

Please list any troops for which you provided assistance. Click on the (+) on the right to add more fields.

Reimbursement Requested

For which resource(s) are you requesting reimbursement?*

Receipts will need to be uploaded below.

Uniforms

Donation Events

Membership Dues

Other

Please provide more details.*

For how many Girl Scouts were purchases made?*

For how many adults were purchases made?*

Total amount requested for reimbursement?*

Upload Receipts*

Drop files here or

Accepted file types: jpg, gif, png, heic, jpeg, pdf, docx, bmp, Max. file size: 50 MB, Max. files: 10.

Reimbursement Information

Do you prefer reimbursement by ACH or check?*

ACH

Check

Bank Name:*

Other Bank Name:*

Bank Account Number:*

Bank Routing Number:*

Other Bank Routing Number:*

Name*

First Last

Address*

Same as previous

Street Address Address Line 2 City State ZIP Code

Signature*

GSGLA volunteer

GSGLA volunteer

Wildfire Assistance Fund Application

Contact Information

Reimbursement Requested

Reimbursement Information

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