EFT_FORM.pdf
PDF 43 KB Posted
- Attached to
- Boston Marathon Ambulance Strike Teams
- Solicitation number
- BD-26-1013-CAO00-FISCL-126661
- Issued by
- Suffolk County, 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 authorize electronic fund transfers for payment processing. Vendors must complete the form by selecting their request type—initial setup, account change, or account closure—and providing comprehensive banking information including their bank name, ABA transit number, and account number. The form requires vendor identification details such as tax identification number, business name, contact person, email, telephone, and complete address. Authorization is executed through an authorized signatory's signature and remains in effect until written cancellation is received by the relevant state department, providing reasonable time for the Office of the Comptroller to process the termination.
The form requires submission of a voided check as supporting documentation and includes attestation language regarding ACH transaction rules and foreign bank account transfers. Vendors must certify that the account information provided is under their direct control and authorize the State Treasurer to initiate, modify, or cancel credit entries as indicated. The authorization grants the state flexibility to manage payments while maintaining vendor control over account termination. This administrative requirement applies to vendors engaged with the Boston Marathon Ambulance Strike Teams contract opportunity or other state department procurement activities and represents a standard prerequisite for payment processing with the Commonwealth of Massachusetts.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 2 CFR 200.326 (Appendix II).docx | DOCX document | |
| Marathon Ambulance Posting 2026.doc | DOC document | |
| Appendix II to Part 200.docx | DOCX document | |
| casl-form.docx | DOCX document |
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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 .