Sample Authorization of Electronic Funds Payment Form~2.pdf

OFFICE OF THE COMPTROLLER

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT FORM

This completed form should be submitted to the requesting department or the department you are currently doing business with.

(Revised November 2023)

Complete this form to enroll, modify, or terminate an existing Electronic Funds Transfer (EFT) agreement with the Commonwealth of Massachusetts departments.

Part I: Reason for Submission See Instructions on Page 3

New Enrollment

Change Enrollment Cancel Enrollment

Document Included (Optional) Voided Check Bank Letter

Part II: Account Holder Information See Instructions on Page 3 Account Holder Legal Name dba Name If different from above

Legal Address Number, Street, Apartment/Suite Number

City State Zip Code

Account Holder Tax Identification Number 9 digits

Employer Identification Number (EIN) Social Security Number (SSN)

Part III: Financial Institution Information See Instructions on Page 3 Financial Institution Name

Routing Number Only 9 digits

Account Number Account Type

Checking Savings

If this is an Enrollment Modification, you must include your old financial institution information or your request will be returned.

Old Financial Institution Name

Old Routing Number Only 9 digits

Old Account Number Old Account Type

Checking Savings

Part IV: Vendor/Customer Information This is the person we will contact for any questions regarding this EFT Authorization

See Instructions on Page 3

Contact Person’s Name Contact Person’s Title

Contact Person’s Phone Contact Person’s Email EXAMPLE

This completed form should be submitted to the requesting department or the department you are currently doing business with.

(Revised November 2023)

Part V: Authorization See Instructions on Page 3 By signing below, 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 Commonwealth of Massachusetts to initiate, change, or cancel credit entries to the 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 by this agreement are not to an account that is subject to being transferred to a foreign bank account.

I affirm that payments authorized by this agreement 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 (CTR) has received written notification from either me or an authorized officer of the 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.

Account Holder Authorized Signature Print Name

Title Date

Part VI: Verification from the Commonwealth Department See Instructions on Page 3 I hereby certify the Vendor/Customer is an authorized signatory and verified by internal records and verbal confirmation initiated by our department.

VCC/VCM Document ID Three letter Department Code

Signature Print Name

Title Phone Number

Date EXAMPLE

This completed form should be submitted to the requesting department or the department you are currently doing business with.

(Revised November 2023)

INSTRUCTIONS

All EFT requests are subject to a 5 (five) day pre-certification period in which all accounts are verified by the qualifying financial institution before any direct deposits are made.

Part I: Reason for Submission Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment, a change to your EFT enrollment account information, or cancellation of your EFT enrollment. The Commonwealth of Massachusetts reserves the right to request additional documentation such as Voided Check as verification of account ownership.

Part II: Account Holder Information

• Account Holder Name: Enter the accounts holder legal name (individual or business name), as reported to the Internal Revenue Service (IRS).

• d/b/a Name: Enter the d/b/a name if applicable.

• Street Address: Enter the account holder’s street address. Enter the account holder’s city, state, and zip code.

• Account Holder Tax Identification Number: Enter the tax identification number as reported to the IRS. If the business is a group, organization or corporation, provide the Federal employer identification number (EIN). If enrolling as an individual provide your Social Security Number.

Part III: Financial Institution Information

• Financial Institution Name: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository that will receive the funds). NOTE: The account name to which EFT payments will be paid is to the name submitted on Part II of this form.

• Routing Number: Enter the bank or financial institutional nine-digit routing number, including applicable leading zeros.

• Account Number: Enter the account holder’s account number with the financial institution, including applicable leading zeros.

• Account Type: Select the account type (Checking or Savings).

• Old Financial Institution Name: Enter your Old Financial Institution’s name (this is the name of the bank or qualifying depository that has been receiving the funds).

• Old Routing Number: Enter the old bank or financial institutional nine-digit routing number, including applicable leading zeros.

• Old Account Number: Enter the old account holder’s account number with the financial institution, including applicable leading zeros.

• Account Type: Enter the old account type (Checking or Savings).

NOTE: Supporting bank documents must be in the account holder legal name only.

Part IV: Contact Information

• Enter the name, title, telephone number, and email address of a contact person who can answer questions about the information submitted on this EFT Authorization Form.

Part V: Authorization

• By your signature on this form, you are certifying that the account is drawn in the Name of an Individual, or the Legal Business Name of the person or entity who has sole control of the account to which EFT deposits are made.

• The EFT authorization form must be signed and dated by the same account holder name in Part II and include a title and telephone number.

• Submit this form electronically, or mail it with with the original signature in black or blue ink to the Commonwealth of Massachusetts Department that you are doing business with.

Part VI: Verification from the Commonwealth Department By your signature on this form, you are certifying that authentication of the vendor/customer’s authorized signatory was conducted by review of the Contractor Signatory Authorization Form (CASL) or by another internal verification process, and additional verification was conducted to confirm banking or address change request. Departments should have multiple known vendor contacts to confirm any registration change. EXAMPLE