Form 10091 VA-FSC Vendor File Request Form

VA-FSC VENDOR FILE REQUEST
FORM INSTRUCTIONS
NOTE:
Only completed forms signed by an “Authorized
Representative” will be processed. Contact information for
any questions / inquiries can be found on the form itself.

Section II: Payee/Vendor Information
* If you are a NEW VENDOR and registered in the System of
Awards Management (SAM) with a Unique Entity Identifier
(UEI) you MUST complete boxes 8 - 11; 14 - 19 plus
Sections III and IV. Additionally, all information provided on
Purpose of Form:
the VA Form 10091 must match the information found in
VA Form 10091 is used to gather essential payment data SAM or your request will not be processed.
from vendors (Commercial, Individuals, Veterans, etc.) to If you are a NEW VENDOR and are NOT registered in SAM,
establish or update vendor records in order to process you MUST complete boxes 11; 14 - 19 plus Sections III and IV.
electronic payments in accordance with Title 31 of the Code
If you are an EXISTING VENDOR and registered in SAM,
of Federal Regulation Part 208 (31 CFR Part 208).
any banking changes MUST be made in SAM. All other
Request Type:
changes would still require an “Authorized Representative” to
If this is the first time registering in our financial system for complete and sign the VA Form 10091.
VA payments, please select NEW VENDOR otherwise 8. Commercial Vendor registered in Sam.gov:
choose UPDATE EXISTING VENDOR and complete
Check box if Payee/Vendor in Section II is registered in
Sections II, III and IV.
SAM.
Section I: VA Facility Information (For Station Use Only):
See * above for mandatory fields to be completed.
1. Station Number:
9. Unique Entity Identify (UEI):
3-digit number of VA Station that is submitting this form.
The (12) character, alphanumeric data element assigned
plus NCA, VHA, VBA.
by SAM.gov.
2. Station Contact:
10. EFT Indicator:
VA employee who completes, signs and submits this form.
The unique 4-character code associated with UEI in Box
9. Blank or incorrect information in this field may cause a
3. Station Phone Number:
delay in processing your request.
Direct number/extension for employee listed in Box 2.
11. SSN/TIN:
4. Station Fax Number:
The 9-digit IRS identifier for the Payee/Vendor in Section
Fax number for office in Box 1.
II. Tax ID Numbers (TINs) are generally assigned to
companies with employees. Employer Identification
5. Station Email Address:
Number (EINs) are typically assigned to a business or
The va.gov email for employee in Box 2.
entity (such as a corporation or an LLC. Individual Tax ID
Numbers (ITINs) assigned to individuals required to file
6. Payee Vendor Type (Required):
taxes but ineligible for a Social Security Number (SSN).
The appropriate vendor type of the Payee/Vendor in
Section II.
12. NPI:
A standard 10-digit unique identifier for medical
• F - Federal Vendor:
providers only. Complete, if applicable.
Include 2-digit Facts.
13. SMALL BUSINESS:
• O - Foreign Vendor:
Check box, if applicable.
Include W8Ben with foreign identification number
14. PAYEE VENDOR NAME:
7. Miscellaneous Actions (If applicable):
Legal name exactly as it appears on file with the Internal
Revenue Service (IRS).
• Assignment of Claims:
Use ONLY if employee in Box 2 is a Contracting 15. DOING BUSINESS AS (DBA):
Officer. Must include “Notice of Assignment” and
If conducting business under another name, complete.
“Instrument of Assignment” with completed form.
16. PAYEE/VENDOR EMAIL:
• LGY Vendor:
Email address for the person listed in Boxes 24 and 25.
Loan Guaranty include 6-digit account number.
17. PAYEE/VENDOR PHONE NUMBER:
Direct number and extension for the person listed in
Boxes 24 and 25.
18. CURRENT ADDRESS:
Provide the address linked to the Payee/Vendor listed in
Box 14 and where all official correspondence will be
sent.
19. PREVIOUS ADDRESS (Required for address change
requests):
Provide the address previously linked to the Payee/
Vendor listed in Box 14 and where all official
correspondence has been sent.
VA FORM 10091, AUG 2023, page 1

Section III: EFT/ACH (Required IAW 31 CFR Part 208):
20. CURRENT BANK NAME:
Provide the name of the Financial Institution linked to the
Payee/Vendor listed in Box 14 and where all payments
for goods/services provided are sent.
21. CURRENT BANK 9-DIGIT ROUTING NUMBER:
The 9-digit number that identifies the bank listed in Box
20 as a member of the American Bankers Association
(ABA). The routing number is usually found in the lowerleft corner at the bottom of a check. Do NOT use a
deposit slip routing number. This will result in a rejected
payment.
22. CURRENT BANK ACCOUNT NUMBER:
The unique set of digits assigned by the Financial
Institution in Box 20 to the account holder linked to the
Payee/Vendor in Box 14.
23. CURRENT ACCOUNT TYPE:
Self-explanatory.

VA FORM 10091, AUG 2023

Section IV: Authorized Representative
Title 18, United States Code, Section 1001 (18 U.S.C. 1001)
makes it a crime to: 1) knowingly and willfully; 2) make any
materially false, fictitious or fraudulent statement or
representation; 3) in any matter within the jurisdiction of the
executive, legislative or judicial branch of the United States.
24. NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:
For the purpose of VA Form 10091, an Authorized
Representative is defined as: the actual Payee/Vendor
listed in Box 14 OR an individual who is designated and
authorized, in writing, to represent the Payee/Vendor
listed in Box 14.
25. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
In signing this form, you certify that you have carefully
read the foregoing instructions to complete this form and
that you understand that a knowing and willful false
statement on this form can be punished by fine or
imprisonment or both (18 U.S.C. 1001).

Page 2

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

VA-FSC VENDOR FILE REQUEST FORM
DATE (MM-DD-YYYY)

REQUEST TYPE

NEW VENDOR

UPDATE EXISTING VENDOR

I. VA FACILITY INFORMATION (For Station Use Only)

II. PAYEE/VENDOR INFORMATION

1. STATION NUMBER

8. COMMERCIAL VENDOR REGISTERED IN SAM.GOV
NCA

VHA

VBA

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

2. STATION CONTACT

3. STATION PHONE NUMBER

4. STATION FAX NUMBER

10. EFT IDENTIFER

11. SSN/TIN

5. STATION EMAIL ADDRESS

6. PAYEE/VENDOR TYPE (Select one)

12. NPI

C - COMMERCIAL

F - FEDERAL AGENCY

C - ADMIN LOAN & ACCT

FACTS ID

I - INDIVIDUAL

O - FOREIGN

I - CAREGIVER

A - AGENT CASHIER

I - HONORARIUM

U - UTILITY

V - VETERAN

C - MEDICAL PROVIDER

7. MISCELLANEOUS ACTIONS (Select one)
ASSIGNMENT OF CLAIMS
WINRS

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

15. DOING BUSINESS AS (DBA)

16. PAYEE/VENDOR EMAIL ADDRESS

(All applicable documents)
BILL OF COLLECTIONS

SETTLEMENT/TORTS

LGY ACCOUNT #

17. PAYEE/VENDOR PHONE NUMBER

18. CURRENT ADDRESS (Include Street, City, State and Zip Code)

FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
VA-FSC CUSTOMER ENGAGEMENT:

19. PREVIOUS ADDRESS (Include Street, City, State and Zip Code)

PHONE: 512-460-5380
EMAIL: [email protected]
FOR ALL OTHER INQUIRIES:

III. EFT/ACH (Required IAW 31 CFR Part 208)

CUSTOMER CARE CENTER: 1-877-353-9791
STATION CARE CENTER: 1-866-372-1141

20. CURRENT BANK NAME

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

21. CURRENT BANK NINE-DIGIT ROUTING 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.

PAPERWORK REDUCTION ACT STATEMENT:
This information is collected in accordance with Section 3507 of
the Paperwork Reduction Act of 1995. We may not
conduct or sponsor, and you are not required to respond to, a
collection of information unless it displays a valid OMB
number. We anticipate that the time expended by all individuals
who complete this form will average 15 minutes. This
includes the time it will take to read instructions, gather the
necessary facts, and fill out the form.

22. CURRENT BANK ACCOUNT NUMBER

23. CURRENT ACCOUNT TYPE
CHECKING

SAVINGS

IV. AUTHORIZED REPRESENTATIVE
CERTIFICATION

In signing this form, you certify that you have carefully read the
foregoing instructions to complete this form and that you
understand that a knowing and willful false statement on this form
can be punished by fine or imprisonment or both (18 U.S.C. 100).
24. NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

25. SIGNATURE OF AUTHORIZED REPRESENTATIVE

NORMAL PROCESSING TIME IS 15 - 30 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
VA FORM
AUG 2023

10091