EFT_FORM.pdf
PDF 43 KB Posted
- Attached to
- RFR-EDUCATION DEPARTMENT CONTRACT SUPPORT
- Solicitation number
- BD-27-1368-CHE01-CHE04-134781
- 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. The form is designed for vendors conducting business with Massachusetts state departments to establish, modify, or terminate electronic fund transfer arrangements for payment processing. The form requires vendors to authorize the State Treasurer as fiscal agent to initiate, change, or cancel credit entries to designated bank accounts and to certify that authorized accounts are under the vendor's direct control. Vendors must specify whether payments will be transferred to foreign bank accounts under International ACH Transaction rules, and the authorization remains in effect until written termination notice is provided to the relevant state department.
The form requests comprehensive vendor and banking information, including the vendor's tax identification number, business name, contact details, bank name, routing number (ABA transit number), and account number, along with designation of account type. Vendors must also provide old account numbers when changing existing banking information and are required to attach a voided check to verify banking details. An authorized representative must sign the form with printed name, title, and date. The completed form should be submitted to the specific Commonwealth department with which the vendor conducts business, and any updates or changes necessitate submission of a revised form to maintain current banking information for state payments.
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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 .