VA Form 10091 - FSC Vendor File Request Form

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

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