EFT_Form_2010.doc
DOC document 30 KB Posted
- Attached to
- Program Goods and Services
- Solicitation number
- S129243-vCurrent
- Issued by
- Middlesex County, Massachusetts
About this file
This document is an Electronic Funds Transfer (EFT) Sign Up Form from the Commonwealth of Massachusetts Office of the Comptroller. The form provides instructions for vendors to authorize the State Treasurer as fiscal agent to initiate, change, or cancel credit entries to their bank accounts. Vendors must provide their bank information, including the account type, transit number, and account number. They must also provide their tax identification number, business name, contact information, and authorized signature. The form indicates that this authorization will remain in effect until canceled in writing or an updated form is submitted.
The form outlines the vendor's responsibility to ensure the account is under their direct control and access. It also requires the vendor to affirm whether the payments authorized are to an account that is subject to being transferred to a foreign bank account. This is to comply with the International/ACH Transaction (IAT) rules. Overall, the form serves to facilitate the electronic transfer of payments from the Commonwealth of Massachusetts to its vendors.
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Text version
COMMONWEALTH OF MASSACHUSETTS
OFFICE OF THE COMPTROLLER
Electronic Funds Transfer Sign Up Form
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 the Comptroller 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.
VENDOR BANK INFORMATION
Vendor Bank Name:
Vendor Bank Transit Number (ABA):
Vendor Bank Account Number:
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:
Attach a voided check here:
File details come from the government source that posted it. Updated .