EFT_FORM~6.pdf
PDF 43 KB Posted
- Attached to
- EMMC DRY ICE
- Solicitation number
- BD-18-1102-SRB00-001-28287
- Issued by
- Suffolk County, Massachusetts
About this file
This document is an Electronic Funds Transfer (EFT) Sign Up Form from the Commonwealth of Massachusetts Office of the Comptroller. It allows vendors to provide their bank account information to the state for the purpose of receiving payments electronically. The form requires the vendor to provide their bank name, transit number, account number, and account type. The vendor must also provide their tax identification number, contact information, and authorize the state treasurer to initiate, change, or cancel credit entries to the provided bank account.
The related state and local contract opportunity is for the provision of EMMC DRY ICE to the Commonwealth of Massachusetts, specifically Suffolk County. No additional details about the contract opportunity are provided in the document.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment A - Bid Sheet~2.xlsx | XLSX spreadsheet | |
| Comm-TermsConditions~14.doc | DOC document | |
| Contractor Authorized Signatory Listing Form~11.docx | DOCX document | |
| standard-contract-frm~13.doc | DOC document | |
| sdp-plan-form-1-commitment~11.docx | DOCX document | |
| W-9~13.doc | DOC document | |
| SRB-EMMC-DRYICE-2018-Final~1.doc | DOC document |
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 .