Electronic-Fund-Transfer~5.doc
DOC document 52 KB Posted
- Attached to
- Dry Ice
- Solicitation number
- BD-18-1102-SRB00-0300-20004
- Issued by
- Barnstable County, Massachusetts
About this file
This document is an Electronic Funds Transfer (EFT) Sign Up Form for vendors to provide banking information to the Commonwealth of Massachusetts Office of the Comptroller. The form allows vendors to initiate, change, or cancel credit entries to their bank account that will be used for payments from the State of Massachusetts. Vendors must provide their bank name, transit number, account number, tax ID number, and contact information. The form requires an authorized signature and a voided check to be attached. This EFT authorization will remain in effect until it is canceled in writing or an updated form is submitted.
The related state and local contract opportunity is for Dry Ice, requested by the State of Massachusetts. No additional details about the contract opportunity are provided in the document.
View the file
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| Attachment A - Bid Sheet.xlsx | XLSX spreadsheet | |
| sdp-plan-form-1-commitment~3.docx | DOCX document | |
| W-9~5.doc | DOC document | |
| SRB-DRY-ICE-2017.doc | DOC document | |
| Comm-TermsConditions~5.doc | DOC document | |
| standard-contract-frm~6.doc | DOC document |
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Text version
COMMONWEALTH OF MASSACHUSETTS
OFFICE OF THE COMPTROLLER
Electronic Funds Transfer Sign Up Form
Request type must be checked:
FORMCHECKBOX
Initial Request
FORMCHECKBOX
Changing Existing Account
FORMCHECKBOX
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:
FORMCHECKBOX
I affirm that payments authorized hereunder are not to an account that is subject to being transferred to a foreign bank account.
FORMCHECKBOX
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:
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 SIGNAUTRE:
Print Name:
Title:
Date:
Form forwarded to Commonwealth Department:
� INCLUDEPICTURE "https://massfinance.state.ma.us/VendorWeb/images/seal.gif" \* MERGEFORMATINET ���
Attach voided check here. � � INCLUDEPICTURE "https://massfinance.state.ma.us/VendorWeb/images/voidCheck.gif" \* MERGEFORMATINET ����
File details come from the government source that posted it. Updated .