EFT_FORM[1].pdf
PDF 43 KB Posted
- Attached to
- RFR for Pharmaceutical Expertise
- Solicitation number
- BD-27-1055-HPC01-HPC-131040
- 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 designed to establish or modify banking arrangements for vendors conducting business with the state. The form serves as authorization for the State Treasurer to initiate, change, or cancel credit entries to vendor accounts through Automated Clearing House (ACH) transactions. Vendors must complete this form to register their banking information with the Massachusetts department from which they receive payment, including their bank name, routing number, account number, and account type. The authorization remains in effect until the vendor submits written notification of termination, providing the Office of Comptroller adequate time to process the cancellation.
The form requires vendors to provide complete identification information, including tax identification number, business name, contact details, and authorized signature from an officer of the organization. Vendors must also clarify whether payments will be transferred to foreign bank accounts, as this affects compliance with International ACH Transaction rules. The vendor is required to attach a voided check to verify account ownership and accuracy of banking information. This form is a prerequisite administrative document for any vendor seeking payment from Massachusetts state agencies and must be submitted to the specific department with which the vendor conducts business.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Business Reference Form~3.docx | DOCX document | |
| HPC RFR OPPA Pharma Consulting~1.doc | DOC document | |
| CEP-Form-Template-16Apr2026.xlsx | XLSX spreadsheet | |
| Contractor_Authorized_Signatory_Listing[1].pdf | ||
| form_w-9[1].pdf | ||
| HPC CNDA template.docx | DOCX document | |
| instructions_standard-contract-form 2.23.2026.pdf | ||
| Prompt_Payment_Discount_Form[1].pdf | ||
| Statement of Work template 52026.docx | DOCX document | |
| form_standard-contract 2.23.2026.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .