authorization-for-electronic-funds-payment-eft~6.pdf
PDF 43 KB Posted
- Solicitation number
- BD-25-1042-OLE-OLE01-113854
- Issued by
- Massachusetts
About this file
This document is an Electronic Funds Transfer (EFT) Sign Up Form issued by the Commonwealth of Massachusetts Office of the Comptroller. The form is designed to authorize the State Treasurer to initiate, change, or cancel credit entries to a specified bank account, with options to indicate whether payments may involve international bank transfers. The form requires vendors to provide comprehensive banking and contact information, including bank transit and account numbers, vendor tax identification, business name, contact details, and address.
The form serves as an official mechanism for vendors doing business with Massachusetts state departments to establish or modify electronic payment methods. It includes provisions for initial requests, account changes, or account closures, and requires an authorized signature from a representative of the vendor organization. The document mandates that the authorization remains in effect until canceled in writing or an updated form is submitted, providing a standardized process for managing state vendor payment accounts. Vendors must also indicate whether their payments are subject to potential transfer to a foreign bank account, enhancing financial transparency and compliance with international transaction rules.
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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 .