36C25718Q0120-006.pdf

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

PAYEE/VENDOR PRINTED NAME & TITLE

SIGNATURE

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

FOR QUESTIONS REGARDING THIS FORM:

NVF CONTACT INFORMATION:

NATIONWIDE VENDOR FILE CUSTOMER SERVICE:

EMAIL: VAFSCVENDOT@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

VA FORM

OCT 2014 10091

mailto:VAFSCVENDOT@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 - include the 6 digit account number OPTIONAL, USE ONLY IF ALAC

· Assignment of Claims- include Notice of Assignment & Instrument of Assignment OPTIONAL, ONLY IF ASSIGNMENT

· Federal Vendors- include the 2 digit Facts ID OPTIONAL, USE ONLY IF FEDERAL AGENCY

· Foreign Vendors- include W8Ben & IRS notice 565(ITIN) or IRS notice 575 (EIN) OPTIONAL, ONLY FOR FOREIGN

COUNTRY

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

21. EFT/ACH (REQUIRED IAW 31CFR Part 208)

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

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

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

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

26. Payee/Vendor Printed Name & Title - Name and title of person completing payee/vendor information. REQUIRED

27. Payee/Vendor Signature - Signature of person completing payee/vendor information. REQUIRED

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

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs logo

FSC VENDOR FILE REQUEST FORM

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

PAYEE/VENDOR PRINTED NAME & TITLE

SIGNATURE

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

FOR QUESTIONS REGARDING THIS FORM:

NVF CONTACT INFORMATION:

NATIONWIDE VENDOR FILE CUSTOMER SERVICE:

EMAIL: VAFSCVENDOT@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

VA FORM

OCT 2014

V A FORM 1 0 0 9 1, OCTOBER 2014

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

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 - include the 6 digit account number OPTIONAL, USE ONLY IF ALAC

· Assignment of Claims- include Notice of Assignment & Instrument of Assignment OPTIONAL, ONLY IF ASSIGNMENT

· Federal Vendors- include the 2 digit Facts ID OPTIONAL, USE ONLY IF FEDERAL AGENCY

· Foreign Vendors- include W8Ben & IRS notice 565(ITIN) or IRS notice 575 (EIN) OPTIONAL, ONLY FOR FOREIGN COUNTRY

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

21. EFT/ACH (REQUIRED IAW 31CFR Part 208)

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

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

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

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

26. Payee/Vendor Printed Name & Title - Name and title of person completing payee/vendor information. REQUIRED

27. Payee/Vendor Signature - Signature of person completing payee/vendor information. REQUIRED

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

Tammy Bailey Missie Vaccaro VA Form 10091, FSC VENDOR FILE REQUEST FORM

OCTOBER 2014

AUGUST 2013

10091, FSC, VENDOR, FILE

C - COMMERCIAL