EFT_FORM.pdf
PDF 43 KB Posted
- Solicitation number
- BD-27-1013-CAO00-FISCL-132116
- 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 use by vendors conducting business with state departments. The form authorizes the State Treasurer as fiscal agent to initiate, change, or cancel credit entries to a vendor's designated bank account for payment purposes. Vendors must complete the form by selecting the appropriate request type—initial setup, modification of existing account information, or account closure—and provide detailed banking information including the vendor's bank name, transit number (ABA), and account number. The form requires vendors to certify that they have direct control over the designated account and to select confirmation regarding whether payments may be transferred to foreign bank accounts in compliance with International ACH Transaction rules. The authorization remains in full force until the Office of Comptroller receives written notice of termination from the vendor or an authorized representative.
The form requires vendors to complete comprehensive vendor information including tax identification number, business name, contact person, email, telephone, mailing address, and other identifying details. Vendors must authorize the form with a signature from an authorized representative and include title, printed name, and date. The form must be submitted to the specific Commonwealth department with which the vendor conducts business, and a voided check must be attached to verify banking information. This EFT authorization streamlines payment processing for state vendors and remains effective until updated or canceled in writing by the vendor.
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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 .