EFT_FORM~5.pdf
PDF 43 KB Posted
- Attached to
- Event Planning and Rental Services
- Solicitation number
- BD-26-1368-CHE01-CHE04-127252
- Issued by
- Massachusetts
About this file
This is an Electronic Funds Transfer Sign Up Form issued by the Commonwealth of Massachusetts Office of the Comptroller, applicable to vendors conducting business with Massachusetts state agencies, including the Massachusetts Veterans Home at Chelsea and Holyoke in connection with the Event Planning and Rental Services contract opportunity. The form authorizes the State Treasurer to initiate, change, or cancel credit entries to a vendor's designated bank account for payment processing. Vendors must complete vendor bank information including the bank name, transit number (ABA), and account number, along with vendor information including tax identification number, business name, contact details, and address. The form allows vendors to indicate whether payments will be transferred to foreign bank accounts in compliance with International ACH Transaction rules. The authorization remains in effect until written cancellation is received by the Office of Comptroller, providing the state reasonable notice to process the termination.
Completion of this form is a mandatory requirement for vendors seeking payment from the Commonwealth of Massachusetts. Vendors must provide a voided check with the form to verify banking information and authorize electronic fund transfers. An authorized representative must sign the form, print their name and title, and provide the date of authorization. The form should be submitted to the specific department with which the vendor does business. This document serves as the financial mechanism for processing vendor payments under state contracts and does not contain pricing terms, set-asides, incumbent information, or funding amounts specific to the Event Planning and Rental Services opportunity.
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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 .