VA10091 Form FY 17.pdf

OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 07-31-2019

VA-FSC VENDOR FILE REQUEST FORM

NEW

VA FACILITY INFORMATION

STATION NUMBER

STATION CONTACT

STATION PHONE NUMBER STATION FAX NUMBER

STATION EMAIL ADDRESS

PAYEE/VENDOR TYPE (Select one)

C - COMMERCIAL

E - EMPLOYEE

I - INDIVIDUAL/HONORARIUM

V - VETERAN

F - FEDERAL AGENCY

O - FOREIGN

A - AGENT CASHIER

U - UTILITY

FACTS ID

MISCELLANEOUS ACTIONS (Select one) WINRS ASSIGNMENT (All applicable documents)

BILL OF COLLECTIONS SETTLEMENT/TORTS

ALAC/LGY ACCOUNT #

UPDATE

DATE

PAYEE/VENDOR INFORMATION

COMMERCIAL VENDOR REGISTERED IN SAM.GOV

(Required IAW FAR 4.1102)

DUNS NUMBER

DUNS+4

SSN/TIN

NPI

SMALL BUSINESS - VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN

SAM OR FURNISH SBA CONFIRMATION

VENDOR NAME

DBA

CONTACT

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 PAYEE/VENDOR

SIGNATURE OF PAYEE/VENDOR

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES

FOR QUESTIONS REGARDING THIS FORM:

CONTACT INFORMATION:

VENDOR CUSTOMER SERVICE SUPPORT HELPDESK:

PHONE: 512-460-5049

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

AUG 2016 10091

mailto:VAFSCCSHD@VA.GOV

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 Payee/Vendor Type - Check the appropriate Payee/Vendor Type box. REQUIRED

Miscellaneous Actions - Check the appropriate Payee/Vendor Type box, some additional documentation required.

OPTIONAL

· ALAC Vendors - USE ONLY IF ALAC include the 6 digit account number

· Assignment of Claims- USE ONLY IF ASSIGNMENT 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

8. Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management & have a DUNS number check this box. OPTIONAL

9. DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B)

OPTIONAL

10. DUNS+4 - If you have more than one EFT account number for the same DUNS number and same physical location as defined by the DUNS address complete this section. OPTIONAL

11. 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

12. NPI - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL

13. Small Business - Check box if applicable OPTIONAL

14. Vendor Name - Provide legal name as it is on file with the IRS REQUIRED

15. DBA - Doing Business As name complete if applicable OPTIONAL

16. Contact - Name of Point of Contact if additional information is required OPTIONAL

17. Email - Point of Contact email address OPTIONAL

18. Phone - Point of Contact phone number OPTIONAL

19. Current Address - Provide your most current address, city, state & zip code REQUIRED

20. Previous Address - Provide previous address, city, state and zip code REQUIRED FOR ADDRESS CHANGES EFT/ACH (REQUIRED IAW 31CFR Part 208)

21. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED

22. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number)

REQUIRED

23. US. Account # - Provide bank account number maximum 17 digits REQUIRED

24. Account Type - Check appropriate box that is associated with account number provide above REQUIRED

25. Name & Title of Payee/Vendor - REQUIRED

26. Signature of Payee/Vendor - 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.

www.reginfo.gov/public/do/PRAMain

OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 07-31-2019 O M B Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 07-31-2019 \\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs logo

VA-FSC VENDOR FILE REQUEST FORM

V A-F S C VENDOR FILE REQUEST FORM

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)

DATE

PAYEE/VENDOR INFORMATION

DUNS NUMBER

DUNS+4

SSN/TIN

NPI

VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN

SAM OR FURNISH SBA CONFIRMATION

VENDOR NAME

DBA

CONTACT

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 PAYEE/VENDOR

SIGNATURE OF PAYEE/VENDOR

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES

FOR QUESTIONS REGARDING THIS FORM:

CONTACT INFORMATION:

VENDOR CUSTOMER SERVICE SUPPORT HELPDESK:

PHONE: 512-460-5049

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

FOR QUESTIONS REGARDING THIS FORM:

CONTACT INFORMATION:

VENDOR CUSTOMER SERVICE SUPPORT HELPDESK:

PHONE: 512-460-5049

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.

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

AUG 2016

V A FORM 1 0 0 9 1, AUGUST 2016

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.

Instructions for F M S Vendor File Request Form

1. NEW box option - Check box if you are a new vendor not in the F M S system.

2. UPDATE box option - Check box if you are an existing vendor in the FMS system.

2. UPDATE box option - Check box if you are an existing vendor in the F M S 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 V A Facility Information

3. Station # - This portion pertains to the V A 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

4. Station Contact Name - V A Station employee. FOR STATION USE ONLY

5. Station Phone - VA Station employee direct number. FOR STATION USE ONLY

5. Station Phone - V A Station employee direct number. FOR STATION USE ONLY

6. Station Fax Number - VA Station fax number. FOR STATION USE ONLY

6. Station Fax Number - V A Station fax number. FOR STATION USE ONLY

7. Station Email - VA Station employee work email address. FOR STATION USE ONLY

7. Station Email - V A Station employee work email address. FOR STATION USE ONLY Payee/Vendor Type - Check the appropriate Payee/Vendor Type box. REQUIRED

Miscellaneous Actions - Check the appropriate Payee/Vendor Type box, some additional documentation required.

OPTIONAL

· ALAC Vendors - USE ONLY IF ALAC include the 6 digit account number

· Assignment of Claims- USE ONLY IF ASSIGNMENT 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 Type - Check the appropriate Payee/Vendor Type box. REQUIRED

Miscellaneous Actions - Check the appropriate Payee/Vendor Type box, some additional documentation required.

OPTIONAL

· ALAC Vendors - USE ONLY IF ALAC include the 6 digit account number

· Assignment of Claims- USE ONLY IF ASSIGNMENT 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

8. Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management & have a DUNS number check this box. OPTIONAL Payee/Vendor Information

8. Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management & have a DUNS number check this box. OPTIONAL

9. DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B) OPTIONAL

9. DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B) OPTIONAL

10. DUNS+4 - If you have more than one EFT account number for the same DUNS number and same physical location as defined by the DUNS address complete this section. OPTIONAL

10. DUNS+4 - If you have more than one E F T account number for the same DUNS number and same physical location as defined by the DUNS address complete this section. OPTIONAL

11. 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

11. S S N/T I N - The Social Security Number (S S N) is the nine-digit number. The Tax Identification Number (T I N) is the nine-digit number which is either an Employer Identification Number (E I N); complete this section with S S N, T I N, E I N or I T I N. REQUIRED

12. NPI - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL

12. N P I - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL

13. Small Business - Check box if applicable OPTIONAL

13. Small Business - Check box if applicable OPTIONAL

14. Vendor Name - Provide legal name as it is on file with the IRS REQUIRED

14. Vendor Name - Provide legal name as it is on file with the I R S REQUIRED

15. DBA - Doing Business As name complete if applicable OPTIONAL

15. D B A - Doing Business As name complete if applicable OPTIONAL

16. Contact - Name of Point of Contact if additional information is required OPTIONAL

16. Contact - Name of Point of Contact if additional information is required OPTIONAL

17. Email - Point of Contact email address OPTIONAL

17. Email - Point of Contact email address OPTIONAL

18. Phone - Point of Contact phone number OPTIONAL

18. Phone - Point of Contact phone number OPTIONAL

19. Current Address - Provide your most current address, city, state & zip code REQUIRED

19. Current Address - Provide your most current address, city, state & zip code REQUIRED

20. Previous Address - Provide previous address, city, state and zip code REQUIRED FOR ADDRESS CHANGES

20. Previous Address - Provide previous address, city, state and zip code REQUIRED FOR ADDRESS CHANGES EFT/ACH (REQUIRED IAW 31CFR Part 208)

21. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED E F T/A C H (REQUIRED IAW 31C F R Part 208)

21. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED

22. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number) REQUIRED

22. U. S. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number) REQUIRED

23. US. Account # - Provide bank account number maximum 17 digits REQUIRED

23. U. S. Account # - Provide bank account number maximum 17 digits REQUIRED

24. Account Type - Check appropriate box that is associated with account number provide above REQUIRED

24. Account Type - Check appropriate box that is associated with account number provide above REQUIRED

25. Name & Title of Payee/Vendor - REQUIRED

25. Name & Title of Payee/Vendor - REQUIRED

26. Signature of Payee/Vendor - REQUIRED

Please fax the completed form to 512-460-5221 for processing.

26. Signature of Payee/Vendor - 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.

PRIVACY ACT NOTICE: The following information is provided to comply with the Privacy Act of 19 74 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 C F R 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 V A Vendor Record. 31 U.S.C. 3322 and 31 C F R 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 O M B control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid O M B control numbers can be located on the O M B Internet Page at www.reginfo.gov/public/do/PRAMain.

Tammy Bailey/Valerie Robinson Missie Vaccaro-Palomaki VA Form 10091, FSC VENDOR FILE REQUEST FORM

AUGUST 2016

JULY 2016

10091, FSC, VENDOR, FILE

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES: Joanie Rhodes

SIGNATURE OF PAYEE/VENDOR.

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES: Joan.Rhodes@va.gov