36C24818Q9679-003.pdf

FMS VENDOR FILE REQUEST FORM

NEW UPDATE

VA FACILITY INFORMATION PAYEE/VENDOR INFORMATION

STATION NUMBER COMMERCIAL VENDOR REGISTERED IN

516 SAM.GOV (Required LAW FAR 4.1102)

STATION CONTACT DUNS NUMBER

Fiscal.FiscalCorporateMailbox@va.gov

STATION PHONE NUMBER STATION FAX NUMBER DUNS+4

727-398-6661 x12201 (727) 299-6715

STATION EMAIL ADDRESS SSN/TIN

Fiscal.FiscalCorporateMailbox@va.gov PAYEE/VENDOR TYPE (Select one) F - FEDERAL AGENCY NPI

C - COMMERCIAL FACTS ID

E - EMPLOYEE O - FOREIGN SMALL BUSINESS - VENDOR MUST BE QUALIFIED

I - INDIVIDUAL/HONORARIUM A - AGENT CASHIER AS SB IN SAM OR FURNISH SBA CONFIRMATION

V - VETERAN U - UTILITY VENDOR NAME

MISCELLANEOUS ACTIONS (Select One) WINRS ASSIGNMENT (All applicable documents) DBA

BILL OF COLLECTIONS SETTLEMENT/TORT

ALAC/LGY ACCOUNT# CONTACT

EMAIL ADDRESS

PHONE NUMBER

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

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

EFT/ACH (Required LAW 31 CFR part 208)

BANK NAME

BANK ADDRESS (Include Street, City, State, and Zip Code)

NINE-DIGIT BANK ROUTING NUMBER

ACCOUNT NUMBER

ACCOUNT TYPE

CHECKING SAVINGS

PAYEE/VENDOR PRINTED NAME & TITLE

SIGNATURE

VA FORM

APR 2014 10091

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