Deborah B. Goldberg
COMMONWEALTH OF MASSACHUSETTS
Department of the State Treasurer
Unclaimed Property Division
One Ashburton Place, 12
th
Floor
Boston, MA 02108-1608
(617) 367-0400
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)
NOTE: This form is in a fillable PDF format. Tab to each open field and key in the desired information.
Then attach the form in an email and send it to: UCPReporting@tre.state.ma.us
.
SECTION 1
HOLDER INFORMATION
EFT - FEDERAL EMPLOYER ID# BRANCH #:
NAME:
ADDRESS:
TELEPHONE:
BANK INFORMATION
NAME:
ADDRESS:
TELEPHONE:
EFT CONTACT INFORMATION
NAME:
SECTION 2
Please select the method of transfer of funds which you intend to use. The banking instructions will be
emailed back to you once approved. Please provide your contact name, telephone number and email
address to receive the instructions.
____ ACH CREDIT ____ WIRE TRANSFER
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.
This method allows you to transfer
funds electronically from one bank to
another.
CONTACT NAME: _______________________________________________
CONTACT TELEPHONE NUMBER: _________________________________
CONTACT EMAIL: _______________________________________________
STATE TREASURY USE ONLY
APPROVED BY _____________________________________ DATE _________________
