10 - New Albany VA Form 10091 - FSC Vendor File Request Form.pdf
VA Form PDF 109 KB Posted
- Solicitation number
- 36C10F24R0055
About this file
This document is a VA-FSC Vendor File Request Form that is used to establish or update a vendor record with the Department of Veterans Affairs (VA). The form collects key information about the vendor such as their name, address, Tax ID number, bank account details, and small business status. It also includes details about the VA facility submitting the form, including the station number, contact information, and vendor type. The form must be completed and submitted via fax for processing, which has an estimated processing time of 3-5 business days. The form is required under 31 U.S.C. 3322 and 31 CFR 210 to enable electronic payment processing through the Automated Clearing House system.
The related federal contract opportunity is for a new outpatient clinic in New Albany, Indiana with Solicitation Number 36C10F24R0055. The contract will be awarded by the VA Office of Construction and Facilities Management. No additional details about the scope of work or requirements are provided in the given documents.
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Text version
OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01-31-2024
VA-FSC VENDOR FILE REQUEST FORM
NEW UPDATE
DATE (MM-DD-YYYY)
VA FACILITY INFORMATION
STATION NUMBER
NCA VHA VBA
STATION CONTACT
STATION PHONE NUMBER STATION FAX NUMBER
STATION EMAIL ADDRESS
PAYEE/VENDOR TYPE (Select one)
C - COMMERCIAL/ALAC
E - EMPLOYEE
I - INDIVIDUAL/HONORARIUM
V - VETERAN
CAREGIVER
F - FEDERAL AGENCY
O - FOREIGN
A - AGENT CASHIER
U - UTILITY
MEDICAL PROVIDER
FACTS ID
MISCELLANEOUS ACTIONS (Select one)
WINRS ASSIGNMENT OF CLAIMS
(All applicable documents)
BILL OF COLLECTIONS SETTLEMENT/TORTS
LGY ACCOUNT #
PAYEE/VENDOR INFORMATION
COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)
UNIQUE ENTITY IDENTIFIER (UEI)
EFT IDENTIFER
SSN/TIN
NPI
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
CURRENT ADDRESSS (Include Street, City, State and Zip Code)
PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)
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
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
VA-FSC CUSTOMER ENGAGEMENT:
PHONE: 512-460-5380
EMAIL: VAFSCCSHD@VA.GOV
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.
VA FORM
MAR 2022 10091 Page 1
Instructions for FMS Vendor File Request Form
1. NEW box option - Check box if you are a new vendor not in the FMS system.
2. 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 Page 2
OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01-31-2024 O M B Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01-31-2024 Department of Veterans Affairs logo
VA-FSC VENDOR FILE REQUEST FORM
V A-F S C VENDOR FILE REQUEST FORM
DATE (MM-DD-YYYY)
VA FACILITY INFORMATION
STATION NUMBER
STATION CONTACT
STATION PHONE NUMBER
STATION FAX NUMBER
STATION EMAIL ADDRESS
PAYEE/VENDOR TYPE (Select one)
FACTS ID
MISCELLANEOUS ACTIONS (Select one)
PAYEE/VENDOR INFORMATION
UNIQUE ENTITY IDENTIFIER (UEI)
EFT IDENTIFER
SSN/TIN
NPI
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
CURRENT ADDRESSS (Include Street, City, State and Zip Code) PREVIOUS ADDRESSS (Include Street, City, State and Zip Code) 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
NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
SIGNATURE OF AUTHORIZED REPRESENTATIVE
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
VA-FSC CUSTOMER ENGAGEMENT:
PHONE: 512-460-5380
EMAIL: VAFSCCSHD@VA.GOV
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.
VA FORM
MAR 2022
V A FORM 10091, MARCH 2022
10091 Instructions for FMS Vendor File Request Form
1. NEW box option - Check box if you are a new vendor not in the FMS system.
2. 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
V A Form 10091, MARCH 2022 VA Form 10091, VA - FSC VENDOR FILE REQUEST FORM
FSC, VENDOR, FILE, 10091
Yolanda Ramos/Nicholas Kerrigan
FSC/047
Missie Vaccaro-Palomaki
MARCH 2022
July 2016
| NEW radio button: |
| UPDATE radio button: |
| DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| V A FACILITY INFORMATION. |
STATION NUMBER.:
| V B A Radio Button: |
| STATION CONTACT.: |
| STATION PHONE NUMBER.: |
| STATION FAX NUMBER.: |
| STATION EMAIL ADDRESS.: |
| SAVINGS radio button: 0 |
| FACTS I D. 2 characters max.: |
| L G Y ACCOUNT NUMBER. 6 characters max.: |
| PAYEE / VENDOR INFORMATION. COMMERCIAL VENDOR REGISTERED IN SAM.GOV (Required I A. W F A. R 4.1102). check box: 0 |
| UNIQUE ENTITY IDENTIFIER (U E I). 13characters max.: |
| E F T IDENTIFER: |
| SOCIAL SECURITY NUMBER / T I N. 9 characters max.: |
| N P I. 10 characters max.: |
| PAYEE / VENDOR NAME.: |
| D B A.: |
| AUTHORIZED REPRESENTATIVE NAME: |
| EMAIL ADDRESS.: |
| PHONE NUMBER.: |
| CURRENT ADDRESSS (Include Street, City, State and Zip Code).: |
| PREVIOUS ADDRESSS (Include Street, City, State and Zip Code).: |
| E F T / A C H (Required I A. W 31 C F R Part 208). |
BANK NAME.:
SIGNATURE OF AUTHORIZED REPRESENTATIVE. This is a digital signature field.
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES:
| NINE-DIGIT BANK ROUTING NUMBER. Enter 9 digit number.: |
| ACCOUNT NUMBER. 17 characters max.: |
| NAME AND TITLE OF AUTHORIZED REPRESENTATIVE: |
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