EFT_FORM HSD FY17-02.pdf
PDF 43 KB Posted
- Attached to
- HSD GB25-09 Grocery Bid
- Solicitation number
- BD-25-1057-HSD01-HSPMT-112899
- 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 direct deposit arrangements for payments from the state. The form requires vendors to specify whether it is an initial request, changing an existing account, or closing an account, and includes certification regarding International ACH Transaction (IAT) rules and whether payments are subject to foreign bank transfers.
The form requires comprehensive vendor information including bank details (bank name, transit/ABA number, account number), tax identification number, business name, contact information, and address. For account changes, the previous account number must be provided. The form must be accompanied by a voided check and submitted to the relevant Commonwealth department with whom the vendor conducts business. The authorization remains in effect until canceled in writing or updated via a new form.
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Other files
| File | Type | Posted |
|---|---|---|
| Dry Goods Bid Sheet GB25-09.xls | XLS spreadsheet | |
| Business Reference Form HSD FY17-02.doc | DOC document | |
| CERTIFICATE OF NON-COLLUSION.docx | DOCX document | |
| Frozen Bid Sheet GB25-09.xls | XLS spreadsheet | |
| Paper Product Bid Sheet GB25-09.xls | XLS spreadsheet | |
| Rev. Frozen Bid Sheet GB25-09.xls | XLS spreadsheet | |
| Rev. Dry Goods Bid Sheet GB25-09.xls | XLS spreadsheet | |
| Grocery Bid Specs HSD GB25-09.rtf | RTF text file | |
| Prompt payment Discount Form.doc | DOC document | |
| Contractor Authorized Signatory Form HSD FY17-02.doc | DOC document | |
| TAX COMPLIANCE CERTIFICATION.docx | DOCX document | |
| w-9 HSD FY17-02.doc | DOC document |
Show all 12
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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 .