EFT_Form_2010.doc
DOC document 30 KB Posted
- Attached to
- Eyewear Frames, Lenses, and Supplies
- Solicitation number
- S161521-vCurrent
- Issued by
- Norfolk County, Worcester County, Foxborough CDP, Massachusetts
About this file
This document is an Electronic Funds Transfer (EFT) Sign Up Form from the Commonwealth of Massachusetts Office of the Comptroller. It allows vendors to provide their banking information to enable the state to initiate, change, or cancel credit entries to their accounts. The form requires vendors to provide their bank name, transit number, account number, account type, tax identification number, contact information, and an authorized signature. Vendors must indicate whether the payments are for an account that is subject to being transferred to a foreign bank account. This authorization remains in effect until the vendor cancels it in writing or submits an updated form.
The form does not contain information about a specific state or local contract opportunity. It is an administrative document used to facilitate electronic payments to vendors doing business with the Commonwealth of Massachusetts.
View the file
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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 .