EFT_new~1.doc
DOC document 68 KB Posted
- Solicitation number
- BD-16-1084-POLGH-GHQ-00000008776
- Issued by
- Middlesex County, Massachusetts
About this file
This document is an Electronic Funds Transfer (EFT) Sign Up Form from the Office of the Comptroller of the Commonwealth of Massachusetts. It allows vendors to authorize the State Treasurer, as fiscal agent for the Commonwealth of Massachusetts, to initiate, change, or cancel credit entries to their bank account. Vendors must provide their bank and contact information, including their Vendor Tax Identification Number, Vendor/Business Name, and Vendor Contact Name. The form requires vendors to indicate whether payments authorized are for an account that is subject to being transferred to a foreign bank account. The authorization remains in effect until canceled in writing or an updated form is submitted.
The form does not contain information about a state or local contract opportunity. It is an administrative document used by the Commonwealth to facilitate electronic payments to vendors.
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Text version
The Official Website of the Comptroller of the Commonwealth (OSC)
Mass.Gov Main Navigation
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COMMONWEALTH OF MASSACHUSETTS
OFFICE OF THE COMPTROLLER
Electronic Funds Transfer Sign Up Form
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 #
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:
Attach voided check here.
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