Bank Fee Reimbursement

Bank Fee Reimbursement
This form is to be used for the reimbursement of:
• “service charge” fees
• “cash deposit” fees
• “excessive deposit” fees

You may submit a request for reimbursement every month, every other month, or on an annual basis.

All requests must be made within one year of being charged.

(For example, if your fee was charged March 2026, you must submit for reimbursement before March 2027).

Attach copies of each month’s bank statement^_* showing fees charged. Requests without bank statements will not be processed by the Finance Department.

Please note, fees vary depending on the bank, and your reimbursment will be calculated accordingly:
- Wells Fargo: $15 fee if account balance is below $2000 throughout the monthly cycle
- WaFd (Washington Federal)L: $5 flat fee, monthly
- National Bank of Arizona: $3/month on some accounts
*To find your bank statement, log into your troop bank account. If you need assistance finding the correct document, please contact Allyson, aisrael@girlscoutssoaz.org or 520-319-3184
WaFd (Washington Federal)Wells FargoNational Bank of Arizona
Full name of Authorized Signer on account:*
Last four digits of Account Number:*
Troop #*
Authorized Signer's Troop Role*
Authorized Signer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Fees
Please note, fees vary depending on the bank, and calculate your reimbursment accordingly:

Wells Fargo: $10 fee if account balance is below $500 throughout the monthly cycle

WaFd (Washington Federal): $5 flat fee, monthly

National Bank of Arizona: $3/month on some accounts

If your service fees differ from the amounts listed above, please contact Allyson at aisrael@girlscoutssoaz.org
Monthly Service Fees
Please provide the MONTH and YEAR for each fee for which you are requesting reimbursment.

Example: January 2025
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
Total Monthly Service Fees
For example, if your account is at WaFd, and you are getting reimbursed for January and February fees, you will add those fees together for a total of $10.
Cash Deposit Fees
Fee #1 Date ; Fee #2 Date ; Fee #3 Date = Total Cash Deposit Fees
Excessive Deposit Fees
Fee #1 Date ; Fee #2 Date ; Fee #3 Date = Total Excessive Deposit Fees
TOTAL REIMBURSEMENT*
Please add all total fees here
Upload copies of each month’s bank statement showing fees charged. Requests without bank statements will not be processed by the Finance Department.*

Cancelof
Authorized Signer Signature*

Clear
Date*

MonthDayYear
Date
Girl Scout Council Staff Signature

Clear
Date*

MonthDayYear
Date
Should be Empty:

Bank Fee Reimbursement

Service Fees

Monthly Service Fees

Cash Deposit Fees

Excessive Deposit Fees