Additional Forms.pdf

COMMONWEALTH OF MASSACHUSETTS ~ STANDARD CONTRACT FORM

(Updated 7/22/2021) Page 1 of 1

This form is jointly issued and published by the Office of the Comptroller (CTR), the Executive Office for Administration and Finance (ANF), and the Operational Services Division (OSD) as the default contract for all Commonwealth Departments when another form is not prescribed by regulation or policy. The Commonwealth deems void any changes made on or by attachment (in the form of addendum, engagement letters, contract forms or invoice terms) to the terms in this published form or to the Standard Contract Form Instructions and Contractor Certifications, the Commonwealth Terms and Conditions for Human and Social Services or the Commonwealth IT Terms and Conditions which are incorporated by reference herein. Additional non-conflicting terms may be added by Attachment. Contractors are required to access published forms at CTR Forms: https://www.macomptroller.org/forms.

Forms are also posted at OSD Forms: https://www.mass.gov/lists/osd-forms.

CONTRACTOR LEGAL NAME:

(and d/b/a):

COMMONWEALTH DEPARTMENT NAME: Massachusetts Department of Correction

MMARS Department Code: DOC

Legal Address: (W-9, W-4): Business Mailing Address: 50 Maple Street, Suite 3, Milford, MA 01757

Contract Manager: Phone: Billing Address (if different):

E-Mail: Fax: Contract Manager: Matthew M. Dailey Phone: 508-422-3340

Contractor Vendor Code: VC E-Mail: Matthew.Dailey@doc.state.ma.us Fax: 508-422-3383

Vendor Code Address ID (e.g. “AD001”): AD .

(Note: The Address ID must be set up for EFT payments.)

MMARS Doc ID(s):

RFR/Procurement or Other ID Number:

___ NEW CONTRACT

PROCUREMENT OR EXCEPTION TYPE: (Check one option only)

__ Statewide Contract (OSD or an OSD-designated Department) __ Collective Purchase (Attach OSD approval, scope, budget) __ Department Procurement (includes all Grants - 815 CMR 2.00) (Solicitation

Notice or RFR, and Response or other procurement supporting documentation) __ Emergency Contract (Attach justification for emergency, scope, budget) __ Contract Employee (Attach Employment Status Form, scope, budget) __ Other Procurement Exception (Attach authorizing language, legislation with specific exemption or earmark, and exception justification, scope and budget)

___ CONTRACT AMENDMENT

Enter Current Contract End Date Prior to Amendment: , 20 .

Enter Amendment Amount: $ . (or “no change”)

AMENDMENT TYPE: (Check one option only. Attach details of amendment changes.)

__ Amendment to Date, Scope or Budget (Attach updated scope and budget)

__ Interim Contract (Attach justification for Interim Contract and updated scope/budget)

__ Contract Employee (Attach any updates to scope or budget)

__ Other Procurement Exception (Attach authorizing language/justification and updated scope and budget)

The Standard Contract Form Instructions and Contractor Certifications and the following Commonwealth Terms and Conditions document are incorporated by reference into this Contract and are legally binding: (Check ONE option): __ Commonwealth Terms and Conditions __ Commonwealth Terms and Conditions For Human and Social Services __ Commonwealth IT Terms and Conditions

COMPENSATION: (Check ONE option): The Department certifies that payments for authorized performance accepted in accordance with the terms of this Contract will be supported in the state accounting system by sufficient appropriations or other non-appropriated funds, subject to intercept for Commonwealth owed debts under 815 CMR 9.00.

__ Rate Contract. (No Maximum Obligation) Attach details of all rates, units, calculations, conditions or terms and any changes if rates or terms are being amended.)

__ Maximum Obligation Contract. Enter total maximum obligation for total duration of this contract (or new total if Contract is being amended). $ .

PROMPT PAYMENT DISCOUNTS (PPD): Commonwealth payments are issued through EFT 45 days from invoice receipt. Contractors requesting accelerated payments must identify a PPD as follows: Payment issued within 10 days __% PPD; Payment issued within 15 days __ % PPD; Payment issued within 20 days __ % PPD; Payment issued within 30 days __% PPD. If PPD percentages are left blank, identify reason: __agree to standard 45 day cycle __ statutory/legal or Ready Payments (M.G.L. c. 29, § 23A); __ only initial payment (subsequent payments scheduled to support standard EFT 45 day payment cycle. See Prompt Pay Discounts Policy.)

BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT: (Enter the Contract title, purpose, fiscal year(s) and a detailed description of the scope of performance or what is being amended for a Contract Amendment. Attach all supporting documentation and justifications.)

ANTICIPATED START DATE: (Complete ONE option only) The Department and Contractor certify for this Contract, or Contract Amendment, that Contract obligations:

__ 1. may be incurred as of the Effective Date (latest signature date below) and no obligations have been incurred prior to the Effective Date.

__ 2. may be incurred as of , 20 , a date LATER than the Effective Date below and no obligations have been incurred prior to the Effective Date.

__ 3. were incurred as of , 20 , a date PRIOR to the Effective Date below, and the parties agree that payments for any obligations incurred prior to the Effective Date are authorized to be made either as settlement payments or as authorized reimbursement payments, and that the details and circumstances of all obligations under this Contract are attached and incorporated into this Contract. Acceptance of payments forever releases the Commonwealth from further claims related to these obligations.

CONTRACT END DATE: Contract performance shall terminate as of , 20 , with no new obligations being incurred after this date unless the Contract is properly amended, provided that the terms of this Contract and performance expectations and obligations shall survive its termination for the purpose of resolving any claim or dispute, for completing any negotiated terms and warranties, to allow any close out or transition performance, reporting, invoicing or final payments, or during any lapse between amendments.

CERTIFICATIONS: Notwithstanding verbal or other representations by the parties, the “Effective Date” of this Contract or Amendment shall be the latest date that this Contract or Amendment has been executed by an authorized signatory of the Contractor, the Department, or a later Contract or Amendment Start Date specified above, subject to any required approvals. The Contractor certifies that they have accessed and reviewed all documents incorporated by reference as electronically published and the Contractor makes all certifications required under the Standard Contract Form Instructions and Contractor Certifications under the pains and penalties of perjury, and further agrees to provide any required documentation upon request to support compliance, and agrees that all terms governing performance of this Contract and doing business in Massachusetts are attached or incorporated by reference herein according to the following hierarchy of document precedence, the applicable Commonwealth Terms and Conditions, this Standard Contract Form, the Standard Contract Form Instructions and Contractor Certifications, the Request for Response (RFR) or other solicitation, the Contractor’s Response (excluding any language stricken by a Department as unacceptable, and additional negotiated terms, provided that additional negotiated terms will take precedence over the relevant terms in the RFR and the Contractor’s Response only if made using the process outlined in 801 CMR 21.07, incorporated herein, provided that any amended RFR or Response terms result in best value, lower costs, or a more cost effective Contract.

AUTHORIZING SIGNATURE FOR THE CONTRACTOR:

X: . Date: .

(Signature and Date Must Be Captured At Time of Signature)

Print Name: .

Print Title: .

AUTHORIZING SIGNATURE FOR THE COMMONWEALTH:

X: . Date: .

(Signature and Date Must Be Captured At Time of Signature)

Print Name: .

Print Title: .

http://www.macomptroller.org/wp-content/uploads/instructions_standard-contract-form.pdf http://www.macomptroller.org/wp-content/uploads/instructions_standard-contract-form.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-human-and-social-services.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-information-technology.pdf https://www.macomptroller.org/forms https://www.mass.gov/lists/osd-forms https://www.mass.gov/law-library/815-cmr http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-human-and-social-services.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-human-and-social-services.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-information-technology.pdf https://www.mass.gov/law-library/815-cmr https://malegislature.gov/Laws/GeneralLaws/PartI/TitleIII/Chapter29/Section23A https://www.mass.gov/law-library/801-cmr tsmyers Typewritten Text tsmyers Typewritten Text

Massachusetts Department of Correction

Volunteer and Contractor Training and Acknowledgement of Prison Rape Elimination

Act (PREA) - Attachment IV

I have been informed of and understand each of the following specific items about the PRISON RAPE ELIMINATION ACT (PREA) of 2003 listed below:

(1)

Federal law specific to incarcerated persons, the Prison Rape Elimination Act (PREA) of 2003, requires that the Department of Correction (DOC) take steps to prevent staff-on inmate and inmate on inmate sexual contact of any type from occurring in or around DOC facilities and/or property.

(2)

The Department has zero tolerance toward all forms of sexual abuse and sexual harassment and is committed to preventing, detecting, and responding to such conduct as outlined in 103 DOC 519 - SEXUALLY ABUSIVE BEHAVIOR PREVENTION AND INTERVENTION POLICY. The Department embraces the standards set forth by the National Prison Rape Elimination Commission and the American Correction Association for all state correctional jurisdictions.

(3) State and Federal law specific to incarcerated persons forbids sexual contact of any type or kind whatsoever by an employee/volunteer or contractor in or around DOC facilities and/or property

(4)

Sexual misconduct between an employee/volunteer or contractor and an inmate is forbidden and may result in discipline up to and including termination and referring for prosecution Department employees, contractors, volunteers and inmates who engage in sexually abusive behavior. Sexual misconduct can consist of conversations, gestures, or correspondence of a sexual nature. This includes demeaning references to gender or sexual preference, or sexually suggestive or derogatory comments about body or clothing, or obscene language or gestures. Sexual misconduct also includes voyeurism which is an invasion of an inmate’s privacy by peering at an inmate in private situations outside of those required by supervisory or security policies and procedures.

(5)

I have a duty to report any sexual misconduct between an employee, volunteer or contractor and an inmate that I observe or have reason to believe occurred and must report it to the Shift Commander as required. If I fail to do so and such is proven pursuant to policy, there could be disciplinary action up to and including termination and/or criminal action.

Print Name Company

Signature Date

COMMONWEALTH OF MASSACHUSETTS

Prompt Pay Discount Form

(Invoice discounts for receiving fast payments)

Revised 3/9/07 Bidder Name: .

Vendor Code (VCUST): .

Contract/RFR Number(s): .

Prompt Payment Discounts (PPD). All contractors/vendors doing business with the Commonwealth must provide a Prompt Payment Discount (PPD) for receiving early payments unless the Contractor/vendor can provide compelling proof that providing a prompt pay discount would be unduly burdensome. Contractors benefit from PPD by increased, usable cash flow as a result of fast and efficient payments for commodities or services rendered. Contractors who agree to accept Electronic Funds Transfer (EFT) increase the prompt pay benefit by ensuring that funds are paid directly to their designated bank accounts, thus eliminating the delay of check clearance policies and traditional mail lead time. Payments processed through the state accounting system (MMARS) can be tracked and verified through the Comptroller’s Vendor Web system using the Vendor/Customer Code assigned to you by a Commonwealth department.

The Commonwealth benefits because contractors reduce the cost of products and services through the applied discount. While Bidders/Contractors have flexibility in determining the actual % discount(s) offered to the Commonwealth, the discount(s) must be identified for 10, 15, 20 and/or 30 days for payment issuance in the column entitled “% Discount Off Proposed Price” below. The Commonwealth may use the prompt pay discounts submitted as a basis for selection and may negotiate discounts as deemed in the best interest of the Commonwealth. The requirement to offer PPD discounts may be waived by the Commonwealth on a case-by-case basis if participation in the program would be unduly burdensome, provided the specific reason for the hardship is outlined below.

All discounts offered will be taken in cases where the payment issue date is within the specified number of days listed below and in accordance with the Commonwealth’s Bill Paying Policy. Payment days will be measured from the date goods are received and accepted / performance was completed OR the date an invoice is received by the Commonwealth, whichever is later to the date the payment is issued as an EFT (preferred method) or mailed by the State Treasurer. The date of payment “issue” is the date a payment is considered “paid” not the date a payment is “received” by a Contractor.

If internal Bidder/Contractor systems require an alternate method of measuring payment issue dates, the Bidder/Contractor must note the issues below or on an attached page if necessary to be considered by the PMT. In cases where the Bidder/Contractor considers that offering a Prompt Payment Discount would be a hardship, the Bidder must clearly define the issues and reasons for said hardship. Providing volume discounts or other discounts on prices is not considered a hardship, since the PPD provides the additional benefit of early cash flow for the Contractor.

Enter the Prompt Payment Discount percentage (%) off the invoice payment, for each of the payment issue dates listed, if the payment is issued within the specified Payment Issue days. For example:

5% - 10 Days 4% - 15 Days 3% - 20 Days 2% - 30 Days

If no discount is offered enter 0% Prompt Payment Discount % Payment Issue Date w/in

% 10 Days % 15 Days % 20 Days % 30 Days

The Contractor is unable to provide a prompt payment discount due to the following hardship:

Contractor/Bidder Authorized Signature _________________________________ Date: ____________

Contractor/ Bidder Authorized Signatory Print Name and Title: __________________________________

Sensitivity Level: Low

Business Reference Form

Reference Guidelines

1. The bidder MUST provide Three (3) business references.

2. References will be contacted to confirm the bidder’s abilities and qualifications as stated in the bidder’s response. The department may deem the bidder’s response unresponsive if a reference is not obtainable from a listed reference after reasonable attempts.

Request for Response (RFR) Information

Bidder:

RFR Name/Title:

RFR Number:

Reference Information

Reference Name: Contact:

Address: Email Address:

Phone Number: Fax/Other Number:

Description and dates(s) of commodities/services provided:

Updated August 2009 Sensitivity level - low

ADDITIONAL ENVIRONMENTALLY PREFERABLE PRODUCTS / PRACTICES

Bidder Company Name: ___________________________________________________ Date: _______________

In line with the Commonwealth’s efforts to promote products and practices which reduce our impact on the environment and human health, Bidders are encouraged provide information regarding their environmentally preferable/sustainable business practices as they relate to this contract wherever possible.

Bidders who can demonstrate such initiatives (referencing, but not limited to, the items listed below) will be eligible to receive evaluation points. In order to receive evaluation points, Bidders must complete this form and submit it with their RFR Response.

Bidders must submit appropriate documentation to support the items for which the Bidder indicated a “Yes” (and/or include information in the box following each question). (See page 2 for additional guidance on completing this form)

1. Packaging

Has the Bidder implemented any of the following environmental initiatives? (A checkmark indicates “Yes”)

____ Use of corrugated materials that exceeds the required minimum of 35% post-consumer recycled content

____ Use of other packaging materials that contain recycled content and are recyclable in most local programs

____ Promotes waste prevention and source reduction by reducing the extent of the packaging and/or offering packaging take-back services, or shipping carton return

____ Reduces or eliminates materials which have been bleached with chlorine or chlorine derivatives

____ Eliminates any packaging that may contain polyvinyl chloride (PVC), or polystyrene or heavy metals

If yes, documentation of practices must be included in the box below, which will expand to accommodate your response.

2. Business Practices / Operations / Manufacturing

Does the bidder engage in practices that serve to reduce or minimize an impact to the environment, including, but not necessarily limited to, the following items? (A checkmark indicates “Yes”)

____ Recycles materials in the warehouse or other operations

____ Use of alternative fuel vehicles or vehicles equipped with diesel emission control devices for delivery or transportation purposes

____ Use of energy efficient office equipment or signage or the incorporation of green building design elements

____ Use of recycled paper (that meets federal specifications) in their marketing and/or resource materials

____ Other sustainable initiative

If yes, documentation of practices must be included in the box below, which will expand to accommodate your response.

3. Training and Education

Does the bidder conduct/offer a program to train or inform customers of the environmental benefits of the products to be offered under this contract, and/or does the bidder conduct environmental training of its own staff? Yes No

If yes, bidders must attach a description of the training offered and the specific criteria targeted by the training in the box below which will expand to accommodate your response.

4. Certifications

Has the bidder or any of its manufacturers and/or subcontractors obtained any of the following product/industry certifications?

____ ISO 14000 or adopted some other equivalent environmental management system

____ Other industry environmental standards (where applicable), such as the CERES principles, LEED

Certification, C2C Protocol, Responsible Care Codes of Practice or other similar standards

____ Third Party product certifications such as Green Seal, Scientific Certification Systems, Smartwood, etc.

A check = “yes”; Bidders must indicate certificate name in the box below and attach a (scanned) copy with their response.

5. Other Environmental Criteria

Bidders are encouraged to respond to criteria specifically indicated in this RFR as “desirable environmental criteria” to receive consideration in the evaluation. (Please provide information in the box which will expand to accommodate your response.)

Commonwealth of Massachusetts

CONTRACTOR AUTHORIZED SIGNATORY FORM

This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy.

Notarized Signature for Individual, Sole-Proprietor or Single Member LLC (must match Form W-9 tax classification)

Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number)

INSTRUCTIONS: Any Contractor, sole-proprietor, or an individual, must provide a notarized signature of the authorized person who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf.

For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.

Signature (ink on paper) Contractor Signature as it will appear on contract or other documents (Complete only in presence of notary)

Print Signatory’s full legal name Title

Certificate of Acknowledgement of Notary Public Before me, the undersigned notary public, the above named individual proved to me through satisfactory evidence of identification, to be the person whose name is signed above and acknowledged to me that (he)/(she) signed for its stated purpose.

Print Notary Name Notary Signature (ink on paper)

Date My commission expires on

AFFIX NOTARY SEAL/STAMP

A copy of this document must be attached to the “record copy” of a contract filed with the department.

Commonwealth of Massachusetts

CONTRACTOR AUTHORIZED SIGNATORY LISTING

This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy.

Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company (must match Form W-9 tax classification)

Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number or Social Security Number)

INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf. In addition to this listing, any state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof of authenticity of signature (a notarized signature that the Department can use to verify that the signature and date that appear on the Contract or other legal document was actually made by the Contractor’s authorized signatory, and not by a representative, designee or other individual.)

For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.

There are three types of electronic signatures that will be accepted on this form: 1) Traditional “wet signature” (ink on paper); 2) Electronic signature that is either: a. hand drawn using a mouse or finger if working from a touch screen device; or b. An upload picture of the signatory’s hand drawn signature; 3) Electronic signature affixed using a digital tool such as Adobe Sign or DocuSign. Typed text of a name not generated by a digital tool, computer generated cursive, or an electronic symbol are not acceptable forms of electronic signature.

Authorized Signatory Name

Signature (Signature as it will appear on contract or other documents)

Title Phone Number

Email Address

Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging the existence of a valid Contract due to an alleged lack of actual authority to execute the document by the signatory.

I certify that I am a responsible authorized officer of the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals identified on this listing are current as of the date of execution and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories above retire, are otherwise terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with the Commonwealth or whenever new signatories are designated.

Please note you cannot self-certify your own signature as a single signer listed above.

Signature Date

Print Name Phone Number

Title Email Address

A copy of this listing must be attached to the “record copy” of a contract filed with the department.

Form W-9 (Revised April 2022) Massachusetts Substitute Form W-9

Request for Taxpayer Identification Number and Certification

▶ Online instructions at: macomptroller.org/wp-content/uploads/instructions_w-9.pdf

Give this Form to the requestor or the department you are doing business with.

1 Business name/Taxpayer (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name/dba, if different from above.

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.

Check only one of the following seven boxes.

4 Exemptions (codes apply only to certain entities, not individuals;

see instructions on Page 4):

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate Exempt payee code (if any):

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership ▶ ___________________

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check

LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Exemption from FATCA reporting code (if any):

(Applies to accounts maintained outside the U.S.)

Other (see instructions) ▶

5 Legal Address (number, street, and apt. or suite no.) See instructions. Requester’s name and address (optional)

6 City, state, and ZIP code

7 Remittance Address (if different from Legal Address)

Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN).

However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, on Page 5. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, on Page 5.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number to Give the Requester for guidelines on whose number to enter.

Social security number or Employer identification number

DUNS Number

Please confirm with the state agency if this is required for vendors receiving federal funds.

Unique Entity Identifier (SAM)

As of April 4, 2022, all vendors that receive federal grant funds must submit their Unique Entity Identifier registered in the System of Awards Management (SAM).

Part II Certification Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You check the following box if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, on Page 5.

Item 2 does not apply.

5. I am an active Commonwealth of Massachusetts state employee: (check one)

If yes, I certify compliance with the Massachusetts State Ethics Commission requirements at https://www.mass.gov/ethics.

Yes No

Sign Here

Signature of

U.S. person ▶ Date ▶

Massachusetts Substitute Form W-9 (Rev 4-2022)

P ri n t o r ty p e

S e e S p e c if ic

I n s tr u c ti o n s o n p a g e

OFFICE OF THE COMPTROLLER

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT FORM

This completed form should be submitted to the requesting department or the department you are currently doing business with.

(Revised November 2023)

Complete this form to enroll, modify, or terminate an existing Electronic Funds Transfer (EFT) agreement with the Commonwealth of Massachusetts departments.

Part I: Reason for Submission See Instructions on Page 3

New Enrollment

Change Enrollment Cancel Enrollment

Document Included (Optional) Voided Check Bank Letter

Part II: Account Holder Information See Instructions on Page 3 Account Holder Legal Name dba Name If different from above

Legal Address Number, Street, Apartment/Suite Number

City State Zip Code

Account Holder Tax Identification Number 9 digits

Employer Identification Number (EIN) Social Security Number (SSN)

Part III: Financial Institution Information See Instructions on Page 3 Financial Institution Name

Routing Number Only 9 digits

Account Number Account Type

Checking Savings

If this is an Enrollment Modification, you must include your old financial institution information or your request will be returned.

Old Financial Institution Name

Old Routing Number Only 9 digits

Old Account Number Old Account Type

Checking Savings

Part IV: Vendor/Customer Information This is the person we will contact for any questions regarding this EFT Authorization

See Instructions on Page 3

Contact Person’s Name Contact Person’s Title

Contact Person’s Phone Contact Person’s Email

This completed form should be submitted to the requesting department or the department you are currently doing business with.

(Revised November 2023)

Part V: Authorization See Instructions on Page 3 By signing below, I hereby certify that the account(s) indicated on this form is under my direct control and access; therefore, I authorize the State Treasurer as fiscal agent for the Commonwealth of Massachusetts to initiate, change, or cancel credit entries to the account(s) as indicated on this form.

For ACH debits consistent with the International ACH Transaction (IAT) rules check one:

I affirm that payments authorized by this agreement are not to an account that is subject to being transferred to a foreign bank account.

I affirm that payments authorized by this agreement are to an account that is subject to being transferred to a foreign bank account.

This authority is to remain in full force and effect until the Office of Comptroller (CTR) has received written notification from either me or an authorized officer of the organization of the account's termination in such time and in such a manner as to afford CTR a reasonable opportunity to act upon it.

Account Holder Authorized Signature Print Name

Title Date

Part VI: Verification from the Commonwealth Department See Instructions on Page 3 I hereby certify the Vendor/Customer is an authorized signatory and verified by internal records and verbal confirmation initiated by our department.

VCC/VCM Document ID Three letter Department Code

Signature Print Name

Title Phone Number

Date

This completed form should be submitted to the requesting department or the department you are currently doing business with.

(Revised November 2023)

INSTRUCTIONS

All EFT requests are subject to a 5 (five) day pre-certification period in which all accounts are verified by the qualifying financial institution before any direct deposits are made.

Part I: Reason for Submission Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment, a change to your EFT enrollment account information, or cancellation of your EFT enrollment. The Commonwealth of Massachusetts reserves the right to request additional documentation such as Voided Check as verification of account ownership.

Part II: Account Holder Information

• Account Holder Name: Enter the accounts holder legal name (individual or business name), as reported to the Internal Revenue Service (IRS).

• d/b/a Name: Enter the d/b/a name if applicable.

• Street Address: Enter the account holder’s street address. Enter the account holder’s city, state, and zip code.

• Account Holder Tax Identification Number: Enter the tax identification number as reported to the IRS. If the business is a group, organization or corporation, provide the Federal employer identification number (EIN). If enrolling as an individual provide your Social Security Number.

Part III: Financial Institution Information

• Financial Institution Name: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository that will receive the funds). NOTE: The account name to which EFT payments will be paid is to the name submitted on Part II of this form.

• Routing Number: Enter the bank or financial institutional nine-digit routing number, including applicable leading zeros.

• Account Number: Enter the account holder’s account number with the financial institution, including applicable leading zeros.

• Account Type: Select the account type (Checking or Savings).

• Old Financial Institution Name: Enter your Old Financial Institution’s name (this is the name of the bank or qualifying depository that has been receiving the funds).

• Old Routing Number: Enter the old bank or financial institutional nine-digit routing number, including applicable leading zeros.

• Old Account Number: Enter the old account holder’s account number with the financial institution, including applicable leading zeros.

• Account Type: Enter the old account type (Checking or Savings).

NOTE: Supporting bank documents must be in the account holder legal name only.

Part IV: Contact Information

• Enter the name, title, telephone number, and email address of a contact person who can answer questions about the information submitted on this EFT Authorization Form.

Part V: Authorization

• By your signature on this form, you are certifying that the account is drawn in the Name of an Individual, or the Legal Business Name of the person or entity who has sole control of the account to which EFT deposits are made.

• The EFT authorization form must be signed and dated by the same account holder name in Part II and include a title and telephone number.

• Submit this form electronically, or mail it with with the original signature in black or blue ink to the Commonwealth of Massachusetts Department that you are doing business with.

Part VI: Verification from the Commonwealth Department By your signature on this form, you are certifying that authentication of the vendor/customer’s authorized signatory was conducted by review of the Contractor Signatory Authorization Form (CASL) or by another internal verification process, and additional verification was conducted to confirm banking or address change request. Departments should have multiple known vendor contacts to confirm any registration change.