EFT_FORM.pdf
PDF 43 KB Posted
- Attached to
- PO 391 Family Reunification Training for NEMTEC
- Solicitation number
- BD-25-1013-PPN00-PPN-115855
- Issued by
- Massachusetts
About this file
This document 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 to provide their banking information to enable electronic payment processing for state departments. Vendors can use this form to initiate a new EFT account, change an existing account, or close an account. The form requires detailed vendor and bank information, including tax identification number, bank transit number, account number, and contact details.
The form includes important authorization provisions, such as the vendor certifying account control and authorizing the State Treasurer to initiate, change, or cancel credit entries. There is also a specific section addressing International ACH Transaction (IAT) rules, where the vendor must indicate whether payments will be transferred to a foreign bank account. The authorization remains in effect until written notification is provided to terminate the account, and the form requires an authorized signature, printed name, title, and date. A voided check must be attached to verify the bank account information.
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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 .