EFT_form.doc

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

Vendor Bank Name:

Vendor Bank Transit Number:

Vendor Bank Account Number:

Account Type:

VENDOR INFORMATION

Vendor Tax Identification Number (TIN):

Vendor/Business Name:

Vendor Contact Name:

E-mail:

Telephone:

Address:

City:

State:

Zip:

PRIVATE

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: Massachusetts Commission for the Deaf and Hard of Hearing

COMMONWEALTH OF MASSACHUSETTS

Authorization for Electronic Funds Transfer Payments

Attach voided check here.

Bank Transit number

Bank Account number