Form VA Form 10091 VA Form 10091 VA-FSC VENDOR FILE REQUEST FORM

OMB Approved No. 2900-NEW
Respondent Burden: 15 Minutes
Expiration Date: XX-XX-XXXX

VA-FSC VENDOR FILE REQUEST FORM
NEW

DATE

UPDATE

VA FACILITY INFORMATION

PAYEE/VENDOR INFORMATION

STATION NUMBER

COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)

STATION CONTACT

DUNS NUMBER

STATION PHONE NUMBER

STATION FAX NUMBER

STATION EMAIL ADDRESS

DUNS+4
SSN/TIN

PAYEE/VENDOR TYPE (Select one)

NPI

C - COMMERCIAL

F - FEDERAL AGENCY

E - EMPLOYEE

O - FOREIGN FACTS ID

I - INDIVIDUAL/HONORARIUM

A - AGENT CASHIER

V - VETERAN

U - UTILITY

MISCELLANEOUS ACTIONS (Select one)

SMALL BUSINESS - VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN
SAM OR FURNISH SBA CONFIRMATION
VENDOR NAME
DBA

WINRS

ASSIGNMENT (All applicable documents)

BILL OF COLLECTIONS

SETTLEMENT/TORTS

CONTACT

ALAC/LGY ACCOUNT #
EMAIL ADDRESS
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
NATIONWIDE VENDOR FILE CUSTOMER SERVICE:
PHONE: 512-460-5049

PHONE NUMBER
CURRENT ADDRESSS (Include Street, City, State and Zip Code)

FOR ALL OTHER INQUIRIES:
CUSTOMER CARE CENTER: 1-877-353-9791
STATION CARE CENTER: 1-866-372-1141

PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)

SUBMIT ALL DOCUMENTATION VIA:
SECURE FAX: 512-460-5221

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

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.

ACCOUNT TYPE
CHECKING

SAVINGS

NAME AND TITLE OF PAYEE/VENDOR

SIGNATURE OF PAYEE/VENDOR

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
VA FORM
MAY 2016

10091

Instructions for FMS Vendor File Request Form
1.
2.

NEW box option - Check box if you are a new vendor not in the FMS system.
UPDATE box option - Check box if you are an existing vendor in the FMS system.

VA Facility Information
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
3.

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.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management & have a DUNS number check this
box. OPTIONAL
DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B)
OPTIONAL
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
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
NPI - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL
Small Business - Check box if applicable OPTIONAL
Vendor Name - Provide legal name as it is on file with the IRS REQUIRED
DBA - Doing Business As name complete if applicable OPTIONAL
Contact - Name of Point of Contact if additional information is required OPTIONAL
Email - Point of Contact email address OPTIONAL
Phone - Point of Contact phone number OPTIONAL
Current Address - Provide your most current address, city, state & zip code REQUIRED
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.