EFT_Form_2009.doc

COMMONWEALTH OF MASSACHUSETTS

Authorization for Electronic Funds Transfer Payments

I, _____________________, hereby authorize the Commonwealth of Massachusetts, through the State Treasurer, to deposit funds due into the account at the bank named below. The State Treasurer is also authorized to debit my account only to adjust any overpayment which has been made to my account.

VENDOR BANK INFORMATION

Bank Name:

Bank Transit Number (ABA):

New Bank Account Number:

( Filling out this field is a requirement for changing an account number (

Old Bank Account Number:

Checking or Savings Account:

VENDOR INFORMATION

Vendor Tax Identification Number:

Vendor/Business Name:

Vendor Contact Name:

E-Mail

Telephone:

Address:

City:

State and Zip Code:

This Authorization will remain in effect until either cancelled 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:

Attach a voided check here