EFT Form~11.doc

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 ether 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:

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:

COMMONWEALTH OF MASSACHUSETTS �OFFICE OF THE COMPTROLLER�Electronic Funds Transfer Sign Up Form