Attachment 5 - Electronic Funds Transfer Sign Up Form.pdf
PDF 43 KB Posted
- Attached to
- CTF Resource Lending Library RFR
- Solicitation number
- BD-16-1037-2CTF0-CTAF-00000007365
- Issued by
- Suffolk County, Massachusetts
About this file
This document is an Electronic Funds Transfer Sign Up Form from the Commonwealth of Massachusetts Office of the Comptroller. It allows vendors to provide their bank account information to initiate, change, or cancel credit entries to their account for payments from the State of Massachusetts. The form requires the vendor to provide their bank name, transit number, account number, account type, and tax ID number, as well as contact information. The vendor must authorize the State Treasurer as the fiscal agent to make these transactions. This form is required for vendors doing business with the Commonwealth of Massachusetts.
The related state and local contract opportunity is for the CTF Resource Lending Library RFR, issued by the Commonwealth of Massachusetts. The key details provided indicate that this is a 'no charge' bid, where vendors should enter a $0 dollar amount when submitting their response through COMMBUYS. No other details about the scope, timeline, or specifics of the contract opportunity are included in the provided information.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment 1 - Standard Contract Form.doc | DOC document | |
| Attachment 2 - Commonwealth Terms and Conditions.doc | DOC document | |
| Attachment 3 - Contractor Authorized Signatory Listing.doc | DOC document | |
| Attachment 4 -W9 Form.doc | DOC document | |
| Childrens Trust Lending Library RFR 2016.doc | DOC document | |
| Attachment 6 - Prompt Payment Discount Form.doc | DOC document |
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Text version
COMMONWEALTH OF MASSACHUSETTS
OFFICE OF THE COMPTROLLER
Electronic Funds Transfer Sign Up Form
This form should be sent to a department with whom you do business.
Request type must be checked: Initial Request Changing Existing Account Closing Account
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 State of Massachusetts to initiate, change or cancel credit entries to that 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 hereunder are not to an account that is subject to being transferred to a foreign bank account.
I affirm that payments authorized hereunder 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 has received written notification, from either me or an authorized officer of 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.
VENDOR BANK INFORMATION
Vendor Bank Name:
Vendor Bank Transit Number (ABA):
Vendor Bank Account Number:
Account Type:
Filling out this field is a requirement for changing account number Vendor Bank Old Account Number:
Account Type:
VENDOR INFORMATION
Vendor Tax Identification Number (TIN):
Vendor/Business Name:
Vendor Contact Name:
E-mail:
Telephone:
Address:
City:
State:
Zip:
This authorization will remain in effect until either canceled in writing or an updated form changing information is sent to the Department you currently do business with.
AUTHORIZED SIGNATURE:
Print Name:
Title:
Date:
Form forwarded to Commonwealth Department:
Attached voided check here:
File details come from the government source that posted it. Updated .