EFT_FORM.pdf
PDF 43 KB Posted
- Attached to
- HSD FY25-10, Meat and Cheese Bid
- Solicitation number
- BD-25-1057-HSD01-HSPMT-113347
- Issued by
- Massachusetts
About this file
This is an Electronic Funds Transfer (EFT) Sign Up Form from the Commonwealth of Massachusetts Office of the Comptroller, used for vendors to establish, modify, or terminate electronic payment arrangements with Massachusetts state departments. The form allows vendors to set up direct deposit for payments from the state, with options for initial requests, changing existing accounts, or closing accounts. Vendors must certify their control over the designated bank account and authorize the State Treasurer to initiate credit entries.
The form requires detailed vendor information including tax identification number, business name, contact information, and banking details (bank name, transit number/ABA, account number). Vendors must also declare whether payments are subject to transfer to foreign bank accounts under International ACH Transaction rules. The form requires attachment of a voided check and must be submitted to the specific department with whom the vendor conducts business. An authorized signature is required, and the authorization remains in effect until canceled in writing or updated via a new form.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Contractor Authorized Signatory Form.doc | DOC document | |
| Meat Cheese Bid Specs FY25-10.rtf | RTF text file | |
| CERTIFICATE OF NON-COLLUSION~2.docx | DOCX document | |
| instructions-for-vendors-responding-to-bids~1.docx | DOCX document | |
| Prompt Payment Discount Form~2.doc | DOC document | |
| W9 form rev April 2022.pdf | ||
| Business Reference Form HSD FY22-02.doc | DOC document | |
| TAX COMPLIANCE CERTIFICATION~4.docx | DOCX document | |
| Meat Cheese Bid Sheet FY25-10.xls | XLS spreadsheet |
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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 .