10091 FSC Vendor File Request

OMB Approved No. 2900-0846
Respondent Burden: 15 Minutes
Expiration Date: 01-31-2024

VA-FSC VENDOR FILE REQUEST FORM
NEW

DATE (MM-DD-YYYY)

UPDATE

VA FACILITY INFORMATION

PAYEE/VENDOR INFORMATION

STATION NUMBER

COMMERCIAL VENDOR REGISTERED IN SAM.GOV
NCA

VHA

VBA

(Required IAW FAR 4.1102)
UNIQUE ENTITY IDENTIFIER (UEI)

STATION CONTACT

STATION PHONE NUMBER

STATION FAX NUMBER

EFT IDENTIFER

SSN/TIN

STATION EMAIL ADDRESS

PAYEE/VENDOR TYPE (Select one)

NPI

C - COMMERCIAL/ALAC

F - FEDERAL AGENCY
FACTS ID

E - EMPLOYEE

O - FOREIGN

I - INDIVIDUAL/HONORARIUM

A - AGENT CASHIER

V - VETERAN

U - UTILITY

CAREGIVER

MEDICAL PROVIDER

MISCELLANEOUS ACTIONS (Select one)
ASSIGNMENT OF CLAIMS
WINRS

(All applicable documents)
BILL OF COLLECTIONS

SETTLEMENT/TORTS

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

DBA

AUTHORIZED REPRESENTATIVE NAME

EMAIL ADDRESS

PHONE NUMBER

LGY ACCOUNT #

CURRENT ADDRESSS (Include Street, City, State and Zip Code)
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
VA-FSC CUSTOMER ENGAGEMENT:
PHONE: 512-460-5380
EMAIL: [email protected]

PREVIOUS 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
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.

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
CHECKING

SAVINGS

NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE OF AUTHORIZED REPRESENTATIVE

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
VA FORM
MAR 2022

10091

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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
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
8. Payee/Vendor Type - Check the appropriate Payee/Vendor Type box. REQUIRED
9. Miscellaneous Actions - Check the appropriate Payee/Vendor Type box, some additional documentation required. OPTIONAL
• LGY Vendors - USE ONLY IF LGY. Include the 6 digit account number.
• Assignment of Claims - USE ONLY IF CONTRACTING OFFICER. 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
9.

Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management (SAM) with UEI Identifier check this box.

10. UEI # - Unique Entity Identifier is (12) character, alphanumeric data element assigned by SAM.gov.
IF REGISTERED IN SYSTEM OF AWARDS MANAGEMENT - REQUIRED
11. EFT INDICATOR - Electronic Funds Transfer Indicator used to identify additional bank accounts associated with a single SAM.gov
registration. OPTIONAL
12. 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
13. NPI - A standard 10 digit unique identifiers for medical providers only, complete this section if applicable.
MEDICAL PROVIDERS ONLY - REQUIRED
14. Small Business - Check box if applicable. OPTIONAL
15. Vendor Name - Provide legal name as it is on file with the IRS. REQUIRED
16. DBA - Doing Business As name complete if applicable. OPTIONAL
17. Authorized Representative Name - Name of Person authorized to make changes on the payee/vendor's behalf. REQUIRED
18. Email - Authorized Representative email address. REQUIRED (Caregivers/Veterans exempted if no email address.)
19. Phone - Authorized Representative phone number. REQUIRED
20. Current Address - Provide your most current address, city, state & zip code. REQUIRED
21. Previous Address - Provide previous address, city, state and zip code. REQUIRED FOR ADDRESS CHANGES
EFT/ACH (REQUIRED IAW 31CFR Part 208)
22. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED
23. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number). REQUIRED
24. US. Account # - Provide bank account number maximum 17 digits. REQUIRED
25. Account Type - Check appropriate box that is associated with account number provide above. REQUIRED
26. Name & Title of Authorized Representative - Printed Name. REQUIRED
27. Signature of Authorized Representative - HANDWRITTEN SIGNATURE 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.

VA FORM 10091, MAR 2022

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