Bad Check Form

A Bad Check Form should be submitted if a check deposited into a troop or service unit bank account bounces, so the troop or service unit can receive reimbursement for the amount of the check and any fees associated. The bank may refer to this as a chargeback or returned check. The Bad Check Form can be completed by any registered volunteer who has access to the troop or service unit bank account.

All checks must be deposited into the troop bank account within 30 days from the date the check was written. If a troop received a chargeback or returned check, they must submit a Bad Check Form within 30 days of receiving the chargeback or returned check, otherwise the troop or service unit will not be reimbursed. Girl Scouts of Greater Iowa will also not reimburse a troop or service unit for a check that is more than 90 days old.

Please view our Bad Check FAQ for more information on what to do if your troop or service unit receives a bad check in payment during the Product Programs. After reviewing this FAQ and gathering the related documents, fill out the Bad Check Form below.

In addition to completing the Bad Check Form, be sure to mail all returned checks to the Des Moines Leadership Center at 10715 Hickman Road, Des Moines, IA 50322.

Service Unit Number

Troop Number

Person Submitting the form:

First Name

Last Name

Street Address 1

Street Address 2

City

State / Province

Postal / Zip Code

Country

Phone Number

Email Address

Returned Check Information

Name Printed on Check #1

Check Amount #1

$00.00

Bank Fee Amount #1

$00.00

Name Printed on Check #2

Check Amount #2

$00.00

Bank Fee Amount #2

$00.00

Name Printed on Check #3

Check Amount #3

$00.00

Bank Fee Amount #3

$00.00

Name Printed on Check #4

Check Amount #4

$00.00

Bank Fee Amount #4

$00.00

Totals

Total Check Amount

$00.00

Total Bank Fee

$00.00

Copy of Chargeback Notice Sent from Bank

By clicking "Submit," you are confirming that all information within this form, including the attached document, is complete and truthful.

After submitting your form, be sure to mail the returned check(s) to 10715 Hickman Road, Des Moines, IA 50322.