Fillable Printable VA Form 10091
Fillable Printable VA Form 10091
VA Form 10091
OMB Approved No. 2900-0846
Respondent Burden: 15 Minutes
Expiration Date: 07-31-2019
VA-FSC VENDOR FILE REQUEST FORM
NEW
VA FACILITY INFORMATION
STATION NUMBER
STATION CONTACT
STATION PHONE NUMBERSTATION FAX NUMBER
STATION EMAIL ADDRESS
PAYEE/VENDOR TYPE (Select one)
C - COMMERCIAL
E - EMPLOYEE
I - INDIVIDUAL/HONORARIUM
V - VETERAN
F - FEDERAL AGENCY
O - FOREIGN
A - AGENT CASHIER
U - UTILITY
FACTS ID
MISCELLANEOUS ACTIONS (Select one)
WINRS
ASSIGNMENT (All applicable documents)
BILL OF COLLECTIONSSETTLEMENT/TORTS
ALAC/LGY ACCOUNT #
UPDATE
DATE
PAYEE/VENDOR INFORMATION
COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)
DUNS NUMBER
DUNS+4
SSN/TIN
NPI
SMALL BUSINESS -
PAYEE/VENDOR MUST BE QUALIFIED AS SMALL
BUSINESS IN SAM OR FURNISH SBA CONFIRMATION
PAYEE/VENDOR NAME
DBA
CONTACT
EMAIL ADDRESS
PHONE NUMBER
CURRENT ADDRESSS (Include Street, City, State and Zip Code)
PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)
EFT/ACH (Required IAW 31 CFR Part 208)
BANK NAME
BANK ADDRESSS (Include City, State and Zip Code)
NINE-DIGIT BANK ROUTING NUMBER
ACCOUNT NUMBER
ACCOUNT TYPE
CHECKINGSAVINGS
NAME AND TITLE OF PAYEE/VENDOR
SIGNATURE OF PAYEE/VENDOR
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
VA-FSC CUSTOMER SERVICE HELP DESK:
PHONE: 512-460-5380
EMAIL: [email protected]
FOR ALL OTHER INQUIRIES:
CUSTOMER CARE CENTER: 1-877-353-9791
STATION CARE CENTER: 1-866-372-1141
SUBMIT ALL DOCUMENTATION VIA:
SECURE FAX: 512-460-5221
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy
Act of 1974 (P.L. 93-579). All information collected on this form
is required under the provisions of 31 U.S.C. 3322 and 31 CFR
210. This information will be used by the Treasury Department to
transmit payment data, by electronic means to vendor's financial
institution. Failure to provide the requested information may delay
or prevent the receipt of payments through the Automated
Clearing House Payment System.
VA FORM
SEP 2017
10091
Instructions for FMS Vendor File Request Form
1. NEW box option - Check box if you are a new vendor not in the FMS system.
2. UPDATE box option - Check box if you are an existing vendor in the FMS system.
VA Facility Information
3. Station # - This portion pertains to the VA Station submitting this form, provide your station 3 digit station number. FOR STATION USE
ONLY
4. Station Contact Name - VA Station employee. FOR STATION USE ONLY
5. Station Phone - VA Station employee direct number. FOR STATION USE ONLY
6. Station Fax Number - VA Station fax number. FOR STATION USE ONLY
7. Station Email - VA Station employee work email address. FOR STATION USE ONLY
Payee/Vendor Type - Check the appropriate Payee/Vendor Type box. REQUIRED
Miscellaneous Actions - Check the appropriate Payee/Vendor Type box, some additional documentation required.
OPTIONAL
· ALAC Vendors - USE ONLY IF ALAC include the 6 digit account number
· Assignment of Claims- USE ONLY IF ASSIGNMENT include Notice of Assignment & Instrument of Assignment
· Federal Vendors- USE ONLY IF FEDERAL AGENCY include the 2 digit Facts
· Foreign Vendors- USE ONLY FOR FOREIGN COUNTRY include W8Ben with foreign identification number
Payee/Vendor Information
8. Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management & have a DUNS number check this
box. OPTIONAL
9. DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B)
OPTIONAL
10. DUNS+4 - If you have more than one EFT account number for the same DUNS number and same physical location as defined by the DUNS
address complete this section. OPTIONAL
11. SSN/TIN - The Social Security Number (SSN) is the nine-digit number. The Tax Identification Number (TIN) is the nine-digit number which
is either an Employer Identification Number (EIN); complete this section with SSN, TIN, EIN or ITIN. REQUIRED
12. NPI - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL
13. Small Business - Check box if applicable OPTIONAL
14. Vendor Name - Provide legal name as it is on file with the IRS REQUIRED
15. DBA - Doing Business As name complete if applicable OPTIONAL
16. Contact - Name of Point of Contact if additional information is required OPTIONAL
17. Email - Point of Contact email address OPTIONAL
18. Phone - Point of Contact phone number OPTIONAL
19. Current Address - Provide your most current address, city, state & zip code REQUIRED
20. Previous Address - Provide previous address, city, state and zip code REQUIRED FOR ADDRESS CHANGES
EFT/ACH (REQUIRED IAW 31CFR Part 208)
21. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED
22. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number)
REQUIRED
23. US. Account # - Provide bank account number maximum 17 digits REQUIRED
24. Account Type - Check appropriate box that is associated with account number provide above REQUIRED
25. Name & Title of Payee/Vendor - REQUIRED
26. Signature of Payee/Vendor - REQUIRED
Please fax the completed form to 512-460-5221 for processing.
PRIVACY ACT NOTICE: The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information
collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury
Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay
or prevent the receipt of payments through the Automated Clearing House Payment System.
RESPONDENT BURDEN: The Nationwide Vendor File Division needs this information to establish, modify/change your VA Vendor Record.
31 U.S.C. 3322 and 31 CFR 210, allow us to ask for this information. We estimate that you will need an average of 15 minutes to review the
instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control
number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can
be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain
.
