Vendor 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.