EFT_FORM HSD FY15-05.pdf

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: