Outstanding Balance Form - Girl Scouts Of North Carolina

Girl Scouts - North Carolina Coastal Pines, Inc.

For Office Use Only

Debtor Last Name:

OUTSTANDING BALANCE FORM

Date Received:

Debtor First Name:

Entered in db:

Troop:

Record ID:

County and Area #:

Debtor Contact Information

Home Ph: (

)

Wk Ph: (

)

Cell Ph: (

)

Debtor is:

Leader/Cookie Mgr

E-mail address:

Parent

Street Address (no PO Boxes):

Customer/Other

City, State and Zip:

Cookie Seller's Name:

Driver's License #:

State Issued:

Troop Paid in Full?

Yes

No

Please provide a brief explanation of situation and why debtor has not paid for cookies.

Contact with Debtor

Summary of Cookies Received and Paid For

Date

By Whom

How (phone/visit/mail/email)

# boxes received/signed for

$

Total cost of cookies signed for

minus $

Total payments made

equals $

Amount still due as of ____________________ (date)

Supporting Documentation (please check all that are enclosed)

Parent Permission Form

G-2 Girl Sale Report

Volunteer Agreement

NSF Check(s)

Signed Receipts

Other (describe _________________________________________________)

Primary Troop Contact Regarding this Debt

Leader/Cookie Mgr (circle one)

Name:

Email address:

Address:

City, State and Zip:

Home Ph: (

)

Wk Ph: (

)

Cell Ph: (

)

I understand that the debtor's name has been submitted to Product Sales Department and that they will do all they can to help collect this debt on behalf of my troop. I can and should also

continue to try and contact this debtor and try to collect the debt as well. If myself or my troop is successful in collecting any money from the debtor, I will notify the Product Sales Dept.

right away with what was collected so all files on this collection will be accurate at all times.

Printed Name of Person Submitting T-5

Signature

Date

If mailed send to Girl Scouts - NCCP, Attn: Product Sales, 6901 Pinecrest Road, Raleigh NC 27613