eft_form.pdf

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.

Please complete all fields below, print it and mail to your contact at the Department you do business with.

Request type must be checked:

I affirm that payments authorized hereunder are not to an account that is subject to being transferred to a foreign bank account.

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:

VENDOR BANK INFORMATION

Vendor Bank Name: _____________________________________________________

Vendor Bank Transit Number (ABA):________________________________________

Vendor Bank Account Number:_____________________________________________

Vendor Bank Old Account Number:_________________________________________

(Filling out this field is a requirement for changing account #)

Account Type:_______________________________

VENDOR INFORMATION

* Vendor Tax Identification Number (TIN):___________________________________

Vendor/Business Name:_________________________________________________

Vendor Contact Name:__________________________________________________

E-mail:_______________________________ Telephone:_____________________________

Address:___________________________________________

City:____________________________ State: _________Zip: _________________

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COMMONWEALTH OF

MASSACHUSETTS

OFFICE OF THE COMPTROLLER

Electronic Funds Transfer Sign up Form

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:

* TIN is your Vendor Tax Identification Number

Attach voided check here.

© 2009 Commonwealth of Massachusetts

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