36H79719R0007-004.pdf

FSC VENDOR FILE REQUEST FORM

NEW UPDATE

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 #

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

APR 2014 10091

mailto:VAFSCVENDOT@VA.GOV

Instructions for FSC 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.

4. Station Contact Name – VA Station employee

5. Station Phone – VA Station employee direct number

6. Station Fax Number- VA Station fax number

7. Station Email- VA Station employee work email address

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

• ALAC Vendors- include the 6 digit account number

• Assignment of Claims- include Notice of Assignment & Instrument of Assignment

• Federal Vendors- include the 2 digit Facts ID

• Foreign Vendors- include W8Ben & IRS notice 565(ITIN) or IRS notice 575 (EIN)

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.

9. DUNS #- Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B) and is a required data element for all registrants in SAM complete this section.

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.

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.

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

13. Small Business- Check box if applicable

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

15. DBA- Doing Business As name complete if applicable

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

17. Email- Point of Contact email address

18. Phone- Point of Contact phone number

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

20. Previous Address- Provide previous address, city, state and zip code

EFT/ACH (Required IAW 31CFR Part 208)

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

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

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

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

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

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

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

*Note: Privacy regulations prevent the VA from accepting documents via email.