EFT_FORM HSD FY17-02.pdf
PDF 43 KB Posted
- Attached to
- HSD FY23-03, Grocery Bid
- Solicitation number
- BD-23-1057-HSD01-HSPMT-78464
- Issued by
- Massachusetts
About this file
The document is an Electronic Funds Transfer Sign Up Form from the Commonwealth of Massachusetts Office of the Comptroller. This form is used by vendors to authorize the State Treasurer as the fiscal agent for the State of Massachusetts to initiate, change, or cancel credit entries to their bank account. Vendors must provide their banking information, tax identification number, and contact details on the form. The authorization remains in effect until it is canceled in writing or an updated form is submitted.
The related state and local contract opportunity is for HSD FY23-03, Grocery Bid, issued by the Commonwealth of Massachusetts. The contract is for the provision of grocery products and services, but the document does not provide any additional details about the scope, quantities, response dates, award dates, or contract term.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Master Dry Goods Bid Sheet FY23-03.xls | XLS spreadsheet | |
| Business Reference Form HSD FY17-02.doc | DOC document | |
| Master Paper Product Bid Sheet FY23-03.xls | XLS spreadsheet | |
| TAX COMPLIANCE CERTIFICATION.docx | DOCX document | |
| Grocery Bid Specs HSD FY23-03~1.rtf | RTF text file | |
| Master Frozen Bid Sheet FY23-03.xls | XLS spreadsheet | |
| Contractor Authorized Signatory Form HSD FY17-02.doc | DOC document | |
| Prompt payment Discount Form.doc | DOC document | |
| CERTIFICATE OF NON-COLLUSION.docx | DOCX document | |
| w-9 HSD FY17-02.doc | DOC 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 .