EFT form.docx
DOCX document 29 KB Posted
- Attached to
- FAC 88 ATV & Snowmobile with trailers
- Solicitation number
- BD-20-1020-DCRCU-DC250-47556
- Issued by
- 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 authorize the State Treasurer to initiate, change, or cancel credit entries to their bank account. The form collects the vendor's bank information, including the bank name, transit number, account number, and account type. It also requires the vendor's tax identification number, business name, contact information, and address. The authorization remains in effect until the vendor cancels it in writing or submits an updated form.
The form does not provide details about any specific state or local contract opportunity. It is an administrative document used to facilitate electronic payments between the Commonwealth of Massachusetts and its vendors.
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 Comptroller has received written notification, from ether 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: |
| _________________________ |
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:
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