Authorization Agreement For Electronic Funds Transfer (Eft) Form printable pdf download

Authorization Agreement For Electronic Funds Transfer (Eft) Form

Commonwealth of Massachusetts

AUTHORIZATION AGREEMENT FOR

ELECTRONIC FUNDS TRANSFER (EFT)

SECTION 1

HOLDER INFORMATION

EFT-FEDERALEMPLOYER ID#

BRANCH #:

NAME:

ADDRESS:

TELEPHONE:

(

)

BANK INFORMATION

NAME:

ADDRESS:

TELEPHONE:

(

)

EFT CONTACT INFORMATION

NAME:

SECTION II

ACH CREDIT

This method allows you to transfer funds by instructing your ACH participating financial institution to debit your account and credit

the Commonwealth of Massachusetts’ bank account. These remittances must be in NACHA CTX format.

SIGNATURE ____________________________________________

DATE _______________________

Return or fax to: Commonwealth of Massachusetts

Unclaimed Property Division

One Ashburton Place, 12th Floor

Boston, Massachusetts 02108 - 1608

Tel. (617) 367-3900 Fax (617) 248-3944

FOR USE OF THE OFFICE OF THE STATE TREASURER ONLY

Your enrollment in the State Treasurer’s EFT program has been approved to commence on ________________

(Date)

Unclaimed Property

By: ___________________________

_____________________

Signature

Date

___________________________

Telephone

Authorization Agreement For Electronic Funds Transfer (Eft) Form