COMMONWEALTH OF MASSACHUSETTS AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER PAYMENTS "I,_______________________________________________, hereby authorize the Commonwealth of Massachusetts, through the State Treasurer, to deposit funds due into the account at the bank named below. The State Treasurer is also authorized to debit my account only to adjust any over deposit which it has caused to be made to my account." Request Type must be checked: Initial Request Changing Existing Request Closing Account MEMBER BANK INFORMATION: Bank Name:_____________________________________________________________ Bank Transit Routing Number: ____ ____ ____ ____ ____ ____ ____ ____ ____ Bank Account Number:____________________________________________________ (Please Check Account Type): _____ Checking Account (attach voided check) _____ Savings Account (attach a bank issued memo with routing and account information) MEMBER INFORMATION: Social Security Number: ____ ____ ____ ____ ____ ____ ____ ____ ____ Name: __________________________________________________________ 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: Executive Office of Health and Human Services MassHealth Accounting Unit ­ EFT 600 Washington Street Boston, MA 02111 SIGNATURE: _________________________________________________________ Print Name: ______________________________________ Date: ________________ Attach voided check here. EFT-M (Rev. 12/11)