EFT_FORM.pdf
PDF 43 KB Posted
- Solicitation number
- BD-26-1013-CAO00-FISCL-128798
- Issued by
- Massachusetts
About this file
This is an Electronic Funds Transfer (EFT) Sign Up Form issued by the Commonwealth of Massachusetts Office of the Comptroller for vendors conducting business with state departments. The form authorizes the State Treasurer to initiate, change, or cancel credit entries to vendor bank accounts for payment purposes. Vendors must complete sections for request type (initial request, account change, or account closure), vendor banking information including bank name, transit number, and account number, and vendor identification details such as tax identification number, business name, contact information, and address. The authorization remains in effect until written cancellation is received by the relevant state department, providing the Office of Comptroller reasonable time to process the termination.
Vendors are required to provide banking details and certify that accounts are under their direct control. For ACH transactions, vendors must affirm whether payments may be transferred to foreign bank accounts in accordance with International ACH Transaction rules. A voided check must be attached to the form to verify banking information. The form must be signed by an authorized representative and forwarded to the specific Commonwealth department with which the vendor conducts business. This administrative document establishes the mechanism through which the state processes vendor payments and maintains current banking records for all service providers.
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Text version
COMMONWEALTH OF MASSACHUSETTS
OFFICE OF THE COMPTROLLER
Electronic Funds Transfer Sign Up Form
This form should be sent to a department with whom you do business.
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 either 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:
Account Type:
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:
File details come from the government source that posted it. Updated .