COMMONWEALTH TERMS AND CONDITIONS
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This Commonwealth Terms and Conditions form is jointly
issued by the Executive Office for Administration and
Finance (ANF), the Office of the Comptroller (CTR) and
the Operational Services Division (OSD) for use by all
Commonwealth of Massachusetts (“State”) Departments
and Contractors. Any changes or electronic alterations by either the
Department or the Contractor to the official version of this form, as jointly
published by ANF, CTR and OSD, shall be void. Upon execution of these
Commonwealth Terms and Conditions by the Contractor and filing as prescribed
by the Office of the Comptroller, these Commonwealth Terms and Conditions will
be incorporated by reference into any Contract for Commodities and Services
executed by the Contractor and any State Department, in the absence of a
superseding law or regulation requiring a different Contract form. Performance
shall include services rendered, obligations due, costs incurred, commodities and
deliverables provided and accepted by the Department, programs provided or
other commitments authorized under a Contract. A deliverable shall include any
tangible product to be delivered as an element of performance under a Contract.
The Commonwealth is entitled to ownership and possession of all deliverables
purchased or developed with State funds. Contract shall mean the Standard
Contract Form issued jointly by ANF, CTR and OSD.
1. Contract Effective Start Date. Notwithstanding verbal or other
representations by the parties, or an earlier start date indicated in a Contract, the
effective start date of performance under a Contract shall be the date a Contract
has been executed by an authorized signatory of the Contractor, the Department, a
later date specified in the Contract or the date of any approvals required by law or
regulation, whichever is later.
2. Payments And Compensation. The Contractor shall only be compensated for
performance delivered and accepted by the Department in accordance with the
specific terms and conditions of a Contract. All Contract payments are subject to
appropriation pursuant to M.G.L. C. 29, §26, or the availability of sufficient non-
appropriated funds for the purposes of a Contract, and shall be subject to intercept
pursuant to M.G.L. C. 7A, §3 and 815 CMR 9.00. Overpayments shall be
reimbursed by the Contractor or may be offset by the Department from future
payments in accordance with state finance law. Acceptance by the Contractor of
any payment or partial payment, without any written objection by the Contractor,
shall in each instance operate as a release and discharge of the State from all
claims, liabilities or other obligations relating to the performance of a Contract.
3. Contractor Payment Mechanism. All Contractors will be paid using the
Payment Voucher System unless a different payment mechanism is required. The
Contractor shall timely submit invoices (Payment Vouchers - Form PV) and
supporting documentation as prescribed in a Contract. The Department shall
review and return rejected invoices within fifteen (15) days of receipt with a
written explanation for rejection. Payments shall be made in accordance with the
bill paying policy issued by the Office of the Comptroller and 815 CMR 4.00,
provided that payment periods listed in a Contract of less than forty-five (45) days
from the date of receipt of an invoice shall be effective only to enable a
Department to take advantage of early payment incentives and shall not subject
any payment made within the forty-five (45) day period to a penalty. The
Contractor Payroll System, shall be used only for "Individual Contractors" who
have been determined to be "Contract Employees" as a result of the Department's
completion of an Internal Revenue Service SS-8 form in accordance with the
Omnibus Budget Reconciliation Act (OBRA) 1990, and shall automatically
process all state and federal mandated payroll, tax and retirement deductions.
4. Contract Termination Or Suspension. A Contract shall terminate on the date
specified in a Contract, unless this date is properly amended in accordance with all
applicable laws and regulations prior to this date, or unless terminated or
suspended under this Section upon prior written notice to the Contractor. The
Department may terminate a Contract without cause and without penalty, or may
terminate or suspend a Contract if the Contractor breaches any material term or
condition or fails to perform or fulfill any material obligation required by a
Contract, or in the event of an elimination of an appropriation or availability of
sufficient funds for the purposes of a Contract, or in the event of an unforeseen
public emergency mandating immediate Department action. Upon immediate
notification to the other party, neither the Department nor the Contractor shall be
deemed to be in breach for failure or delay in performance due to Acts of God or
other causes factually beyond their control and without their fault or negligence.
Subcontractor failure to perform or price increases due to market fluctuations or
product availability will not be deemed factually beyond the Contractor's control.
5. Written Notice. Any notice shall be deemed delivered and received when
submitted in writing in person or when delivered by any other appropriate method
evidencing actual receipt by the Department or the Contractor. Any written notice
of termination or suspension delivered to the Contractor shall state the effective
date and period of the notice, the reasons for the termination or suspension, if
applicable, any alleged breach or failure to perform, a reasonable period to cure
any alleged breach or failure to perform, if applicable, and any instructions or
restrictions concerning allowable activities, costs or expenditures by the
Contractor during the notice period.
6. Confidentiality. The Contractor shall comply with M.G.L. C. 66A if the
Contractor becomes a "holder" of "personal data". The Contractor shall also
protect the physical security and restrict any access to personal or other
Department data in the Contractor's possession, or used by the Contractor in the
performance of a Contract, which shall include, but is not limited to the
Department's public records, documents, files, software, equipment or systems.
7. Record-keeping And Retention, Inspection Of Records. The Contractor
shall maintain records, books, files and other data as specified in a Contract and in
such detail as shall properly substantiate claims for payment under a Contract, for
a minimum retention period of seven (7) years beginning on the first day after the
final payment under a Contract, or such longer period as is necessary for the
resolution of any litigation, claim, negotiation, audit or other inquiry involving a
Contract. The Department shall have access, as well as any parties identified
under Executive Order 195, during the Contractors regular business hours and
upon reasonable prior notice, to such records, including on-site reviews and
reproduction of such records at a reasonable expense.
8. Assignment. The Contractor may not assign or delegate, in whole or in part,
or otherwise transfer any liability, responsibility, obligation, duty or interest under
a Contract, with the exception that the Contractor shall be authorized to assign
present and prospective claims for money due to the Contractor pursuant to a
Contract in accordance with M.G.L. C. 106, §9-318. The Contractor must
provide sufficient notice of assignment and supporting documentation to enable
the Department to verify and implement the assignment. Payments to third party
assignees will be processed as if such payments were being made directly to the
Contractor and these payments will be subject to intercept, offset, counter claims
or any other Department rights which are available to the Department or the State
against the Contractor.
9. Subcontracting By Contractor. Any subcontract entered into by the
Contractor for the purposes of fulfilling the obligations under a Contract must be
in writing, authorized in advance by the Department and shall be consistent with
and subject to the provisions of these Commonwealth Terms and Conditions and a
Contract. Subcontracts will not relieve or discharge the Contractor from any duty,
obligation, responsibility or liability arising under a Contract. The Department is
entitled to copies of all subcontracts and shall not be bound by any provisions
contained in a subcontract to which it is not a party.
10. Affirmative Action, Non-Discrimination In Hiring And Employment. The
Contractor shall comply with all federal and state laws, rules and regulations
promoting fair employment practices or prohibiting employment discrimination
and unfair labor practices and shall not discriminate in the hiring of any applicant
for employment nor shall any qualified employee be demoted, discharged or
otherwise subject to discrimination in the tenure, position, promotional
opportunities, wages, benefits or terms and conditions of their employment
because of race, color, national origin, ancestry, age, sex, religion, disability,
handicap, sexual orientation or for exercising any rights afforded by law. The
Contractor commits to purchasing supplies and services from certified minority or
women-owned businesses, small businesses or businesses owned by socially or
economically disadvantaged persons or persons with disabilities.
11. Indemnification. Unless otherwise exempted by law, the Contractor shall
indemnify and hold harmless the State, including the Department, its agents,
officers and employees against any and all claims, liabilities and costs for any
personal injury or property damages, patent or copyright infringement or other
damages that the State may sustain which arise out of or in connection with the
Contractor's performance of a Contract, including but not limited to the
negligence, reckless or intentional conduct of the Contractor, its agents, officers,
employees or subcontractors. The Contractor shall at no time be considered an
agent or representative of the Department or the State. After prompt notification
of a claim by the State, the Contractor shall have an opportunity to participate in
the defense of such claim and any negotiated settlement agreement or judgment.
The State shall not be liable for any costs incurred by the Contractor arising under
this paragraph. Any indemnification of the Contractor shall be subject to
appropriation and applicable law.
12. Waivers. Forbearance or indulgence in any form or manner by a party shall
not be construed as a waiver, nor in any way limit the legal or equitable remedies
available to that party. No waiver by either party of any default or breach shall
constitute a waiver of any subsequent default or breach.
13. Risk Of Loss. The Contractor shall bear the risk of loss for any Contractor
materials used for a Contract and for all deliverables, Department personal or
other data which is in the possession of the Contractor or used by the Contractor in
the performance of a Contract until possession, ownership and full legal title to the
deliverables are transferred to and accepted by the Department.
COMMONWEALTH TERMS AND CONDITIONS
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14. Forum, Choice of Law And Mediation. Any
actions arising out of a Contract shall be governed by the
laws of Massachusetts, and shall be brought and
maintained in a State or federal court in Massachusetts
which shall have exclusive jurisdiction thereof. The
Department, with the approval of the Attorney General's Office, and the
Contractor may agree to voluntary mediation through the Massachusetts Office of
Dispute Resolution (MODR) of any Contract dispute and will share the costs of
such mediation. No legal or equitable rights of the parties shall be limited by this
Section.
15. Contract Boilerplate Interpretation, Severability, Conflicts With Law,
Integration. Any amendment or attachment to any Contract which contains
conflicting language or has the affect of a deleting, replacing or modifying any
printed language of these Commonwealth Terms and Conditions, as officially
published by ANF, CTR and OSD, shall be interpreted as superseded by the
official printed language. If any provision of a Contract is found to be superseded
by state or federal law or regulation, in whole or in part, then both parties shall be
relieved of all obligations under that provision only to the extent necessary to
comply with the superseding law, provided however, that the remaining provisions
of the Contract, or portions thereof, shall be enforced to the fullest extent
permitted by law. All amendments must be executed by the parties in accordance
with Section 1. of these Commonwealth Terms and Conditions and filed with the
original record copy of a Contract as prescribed by CTR. The printed language of
the Standard Contract Form, as officially published by ANF, CTR and OSD,
which incorporates by reference these Commonwealth Terms and Conditions,
shall supersede any conflicting verbal or written agreements relating to the
performance of a Contract, or attached thereto, including contract forms, purchase
orders or invoices of the Contractor. The order of priority of documents to
interpret a Contract shall be as follows: the printed language of the
Commonwealth Terms and Conditions, the Standard Contract Form, the
Department's Request for Response (RFR) solicitation document and the
Contractors Response to the RFR solicitation, excluding any language stricken
by a Department as unacceptable and including any negotiated terms and
conditions allowable pursuant to law or regulation.
IN WITNESS WHEREOF, The Contractor certify under the pains and
penalties of perjury that it shall comply with these Commonwealth Terms
and Conditions for any applicable Contract executed with the
Commonwealth as certified by their authorized signatory below:
CONTRACTOR AUTHORIZED SIGNATORY:_________________________________________________________________________
(signature)
Print Name: ____________________________________________________
Title: __________________________________________________________
Date: __________________________________________________________
(Check One): _______ Organization ________ Individual
Full Legal Organization or Individual Name: ___________________________________________________________________________
Doing Business As: Name (If Different): _______________________________________________________________________________
Tax Identification Number: ____ ____ ____ ____ ____ ____ ____ ____ ____
Address: _______________________________________________________________________________________________________
Telephone: _______________________________________ FAX: _______________________________________________________
INSTRUCTIONS FOR FILING THE COMMONWEALTH TERMS AND CONDITIONS
A “Request for Verification of Taxation Reporting Informationform (Massachusetts Substitute W-9 Format), that contains the
Contractor's correct TIN, name and legal address information, must be on file with the Office of the Comptroller. If the Contractor has not
previously filed this form with the Comptroller, or if the information contained on a previously filed form has changed, please fill out a W-
9 form and return it attached to the executed COMMONWEALTH TERMS AND CONDITIONS.
If the Contractor is responding to a Request for Response (RFR), the COMMONWEALTH TERMS AND CONDITIONS must be
submitted with the Response to RFR or as specified in the RFR. Otherwise, Departments or Contractors must timely submit the completed
and properly executed COMMONWEALTH TERMS AND CONDITIONS (and the W-9 form if applicable) to the: Payee and Payments
Unit, Office of the Comptroller, 9th Floor, One Ashburton Place, Boston, MA 02108 in order to record the filing of this form on the
MMARS Vendor File. Contractors are required to execute and file this form only once.
Clear All
Form W-9
(Massachusetts Substitute W-9 Form)
Rev. April 2009
Request for Taxpayer
Identification Number and Certification
Completed form should be
given to the requesting
department or the department
you are currently doing
business with.
Name ( List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2)
Business name, if different from above. (See Specific Instruction on page 2)
Check the appropriate box: Individual/Sole proprietor Corporation Partnership Other -----------------------------------------------
Legal Address: number, street, and apt. or suite no.
Remittance Address
: if different from legal address number, street, and apt. or
suite no.
City, state and ZIP code
City, state and ZIP code
Phone # ( ) Fax # ( ) Email address:
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social
security number (SSN). However, for a resident alien, sole proprietor, or
disregarded entity, see the Part I instruction on
page 2. For other entities, it is your employer identification number (EIN). If
you do not have a number, see How to get a TIN on page 2.
Note: If the account is in more than one name, see the chart on page 2 for
guidelines on whose number to enter.
Vendors:
Dunn and Bradstreet Universal Numbering System (DUNS))
Social security number
--
OR
Employer identification number
-
DUNS

Part II Certification
Please print or type
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Services (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that
I am no longer subject to backup withholding, and
3. I am an U.S. person (including an U.S. resident alien).
4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No____ Yes _____ If yes, in compliance with the State Ethics
Commission requirements.
Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
Sign
Here
Authorized Signature Date
Purpose of Form
A person who is required to file an information
return with the IRS must get your correct
taxpayer identification number (TIN) to report, for
example, income paid to you, real estate
transactions, mortgage interest you paid,
acquisition or debt, or contributions you made to
an IRA.
Use Form W-9 only if you are a U.S. person
(including a resident alien), to give your correct
TIN to the person requesting it (the requester)
and , when applicable, to:
1. Certify the TIN you are giving is correct (or
you are waiting for a number to be issued).
2. Certify you are not subject to backup
withholding
If you are a foreign person, use the
appropriate Form W-8. See Pub 515,
Withholding of Tax on Nonresident Aliens and
Foreign Corporations.
What is backup withholding? Persons making
certain payments to you must withhold a
designated percentage, currently 28% and pay to
the IRS of such payments under certain
conditions. This is called “backup withholding.”
Payments that may be subject to backup
withholding include interest, dividends, broker and
barter exchange transactions, rents, royalties,
nonemployee pay, and certain payments from
fishing boat operators. Real estate transactions
are not subject to backup withholding.
If you give the requester your correct TIN, make
the proper certifications, and report all your
taxable interest and dividends on your tax return,
payments you receive will not be subject to
backup withholding. Payments you receive will
be subject to backup withholding if:
1. You do not furnish your TIN to the
requester, or
2. You do not certify your TIN when required
(see the Part II instructions on page 2 for
details), or
3. The IRS tells the requester that you furnished
an incorrect TIN, or
4. The IRS tells you that you are subject to
backup withholding because you did not
report all your interest and dividends only), or
5. You do not certify to the requester that you are
not subject to backup withholding under 4 above
(for reportable interest and dividend accounts
opened after 1983 only).
Certain payees and payments are exempt from
backup withholding. See the Part II instructions
on page 2.
Penalties
Failure to furnish TIN. If you fail to furnish your
correct TIN to a requester, you are subject to a
penalty of $50 for each such failure unless your
failure is due to reasonable cause and not to
willful neglect.
Civil penalty for false information with respect
to withholding. If you make a false statement
with no reasonable basis that results in no backup
withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information.
Willfully falsifying certifications or affirmations
may subject you to criminal penalties including
fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses
TINs in violation of Federal law, the requester may
be subject to civil and criminal penalties.
Form MA- W-9 (Rev. April 2009)
What Name and Number to
Give the Requester
For this type of account: Give name and SSN of:
1. Individual
2. Two or more
individuals (joint
account)
3. Custodian account of
a minor (Uniform Gift
to Minors Act)
4. a. The usual
revocable savings
trust (grantor is
also trustee)
b. So-called trust
account that is not
a legal or valid
trust under state
law
5. Sole proprietorship
The individual
The actual owner of the
account or, if combined
funds, the first
individual on the
account
1
The minor
2
The grantor-trustee
1
The actual owner
1
The owner
3
For this type of account: Give name and EIN of:
6. Sole proprietorship
7. A valid trust, estate, or
pension trust
8. Corporate
9. Association, club,
religious, charitable,
educational, or other
tax-exempt organization
10. Partnership
11. A broker or registered
nominee
12. Account with the
Department of
Agriculture in the name
of a public entity (such
as a state or local
government, school
district, or prison) that
receives agricultural
program payments
The owner
3
Legal entity
4
The corporation
The organization
The partnership
The broker or nominee
The public entity
Specific Instructions
Name. If you are an individual, you must
generally enter the name shown on your social
security card. However, if you have changed
your last name, for instance, due to marriage
without informing the Social Security
Administration of the name change, enter your
first name, the last name shown on your social
security card, and your new last name.
If the account is in joint names, list first and
then circle the name of the person or entity
whose number you enter in Part I of the form.
Sole proprietor. Enter your individual name
as shown on your social security card on the
“Name” line. You may enter your business,
trade, or “doing business as (DBA)” name on
the “Business name” line.
Limited liability company (LLC). If you are a
single-member LLC (including a foreign LLC
with a domestic owner) that is disregarded as
an entity separate from its owner under
Treasury regulations section 301.7701-3, enter
the owner’s name on the “Name” line. Enter
the LLC’s name on the “Business name” line.
Caution: A disregarded domestic entity that
has a foreign owner must use the appropriate
Form W-8.
Other entities. Enter your business name as
shown on required Federal tax documents on
the “Name” line. This name should match the
name shown on the charter or other legal
document creating the entity. You may enter
any business, trade, or DBA name on the
“Business name” line.
Part I - Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate
box.
If you are a resident alien and you do not
have and are not eligible to get an SSN, your
TIN is your IRS individual taxpayer
identification number (ITIN). Enter it in the
social security number box. If you do not have
an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an
EIN, you may enter either your SSN or EIN.
However, the IRS prefers that you use your
SSN.
If you are an LLC that is disregarded as an
entity separate from its owner (see Limited
liability company (LLC) above), and are
owned by an individual, enter your SSN (or
“pre-LLC” EIN, if desired). If the owner of a
disregarded LLC is a corporation, partnership,
etc., enter the owner’s EIN.
Note: See the chart on this page for further
clarification of name and TIN combinations.
How to get a TIN. If you do not have a
TIN, apply for one immediately. To apply for an
SSN, get Form SS-5, Application for a Social
Security Card, from your local Social Security
Administration office. Get Form W-7, Application
for IRS Individual Taxpayer Identification Number,
to apply for an ITIN or Form SS-4, Application for
Employer Identification Number, to apply for an
EIN. You can get Forms W-7 and SS-4 from the
IRS by calling 1-800-TAX-FORM (1-800-829-
3676) or from the IRS’s Internet Web Site
www.irs.gov.
If you do not have a TIN, write “Applied For” in
the space for the TIN, sign and date the form, and
give it to the requester. For interest and dividend
payments, and certain payments made with
respect to readily tradable instruments, generally
you will have 60 days to get a TIN and give it to
the requester before you are subject to backup
withholding on payments.
The 60-day rule does not apply to other types of
payments. You will be subject to backup
withholding on all such payments until you
provide your TIN to the requester.
Note: Writing “Applied For” means that you have
already applied for a TIN or that you intend to
apply for one soon.
Part II - Certification
To establish to the paying agent that your TIN is
correct or you are a U.S. person, or resident
alien, sign Form W-9.
For a joint account, only the person whole TIN is
shown in Part I should sign (when required).
Real estate transactions. You must sign the
certification. You may cross out item 2 of the
certification.
Dunn and Bradstreet Universal Numbering
System (DUNS) number requirement –
The United States Office of Management and
Budget (OMB) requires all vendors that receive
federal grant funds have their DUNS number
recorded with and subsequently reported to the
granting agency. If a contractor has multiple
DUNS numbers the contractor should provide the
primary number listed with the Federal
government’s Central Contractor Registration
(CCR) at /www.ccr.gov
. Any entity that does not
have a DUNS number can apply for one on-line
at www.DNB.com under the DNB D-U-N Number
Tab.
Privacy Act Notice
Section 6109 of the Internal Revenue Code
requires you to give your correct TIN to persons
who must file information returns with the IRS to
report interest, dividends, and certain other
income paid to you, mortgage interest you paid,
the acquisition or abandonment of secured
property, cancellation of debt, or contributions
you made to an IRA or MSA. The IRS uses the
numbers for identification purposes and to help
verify the accuracy of your tax return. The IRS
may also provide this information to the
Department of Justice for civil and criminal
litigation, and to cities, states, and the District of
Columbia to carry out their tax laws
You must provide your TIN whether or not you
are required to file a tax return. Payers must
generally withhold a designated percentage,
currently 28% of taxable interest, dividend, and
certain other payments to a payee who does not
give a TIN to a payer. Certain penalties may also
apply.
1
List first and circle the name of the person whose
number you furnish. If only one person on a joint
account has an SSN, that person’s number must be
furnished.
2
Circle the minor’s name and furnish the minor’s SSN.
3
You must show your individual name, but you may
also enter your business or “DBA” name. You may
use either your SSN or EIN (if you have one).
4
.
List first and circle the name of the legal trust, estate,
or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal
entity itself is not designated in the account title.)
Note: If no name is circled when more than one name
is listed, the number will be considered to be that of
the first name listed.
If you have questions on completing this form,
please contact the Office of the State Comptroller.
(617) 973-2468.
Upon completion of this form, please
send it to the Commonwealth of
Massachusetts Department you are
doing business with.
Form MA- W-9 (Rev. April 2009)
Page 2
__________________________________________________________________
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 either 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: _________________________
Account Type: _________________________
Filling out this field is a requirement for changing account number
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:_________________________________
Attached voided check here:
COMMONWEALTH OF MASSACHUSETTS
OFFICE OF THE COMPTROLLER
Electronic Funds Transfer Sign Up Form