Attachment 004 Oracle Supplier Request Form.pdf

Page 1 of 1 May 2018

ORACLE Supplier Request Form

Client: ___________________ Requestor: ____________________

Date: ___________________ Approver: ____________________

By waiving this supplier I attest to this supplier being exempt from the FAR (Federal Acquisition

Regulation).

□ SAM Registration Waived Reason for waiver/FAR Clause #_____________

SAM Waiver approved by:______________________________________________________

□ Add new supplier □ Change existing supplier □ Add site to existing supplier

□ IPP supplier

PRIVACY ACT STATEMENT

This information is requested under 31 U.S.C. 3512; 5 U.S.C. 4111; 5 U.S.C. 5514; 5 U.S.C. 5701, et seq.; and 31

U.S.C. 3711. The primary purpose for collecting this information is to process payment requests and support Federal agency financial transactions. Information may be disclosed to the Department of Treasury to transmit payment data to the supplier, and to other agencies and organizations as authorized pursuant to the published routine uses found in the

DOI-91, Oracle Federal Financials (OFF) system of records notice (80 FR 66551, October 29, 2015), which may be viewed at https://www.doi.gov/privacy/sorn. Furnishing the information is voluntary. However, not providing the requested information may delay or impede processing of requests for payments.

Required □ Employee □Invitational Traveler/Witness

Information: □ Non-Federal □ Federal □ Foreign □ State

□ Subject to Prompt Pay N-30 □ Payment Terms Immediate

Supplier Name:

DUNS Number:

Taxpayer ID:

ALC (if Federal):

Trading Partner ID: (if

Federal)

Mailing Address

Bank Name

Bank Routing Number (ABA):

Bank Account Number:

Checking/Savings:

Optional Information:

Alternate Name:

Telephone Number:

Contact Info:

E-mail Address:

Pay Group □ACH □Travel □Check

IBC Use Only:

The above information has been added/updated into Oracle and data input verified for accuracy according to procedures.

Data input by: ____________________ On date: ___________________

Passed verification by: ____________________ On date: ___________________ kkhoune Highlight kkhoune Highlight kkhoune Highlight kkhoune Highlight kkhoune Highlight kkhoune Highlight etwyman Highlight etwyman Highlight

Page 1 October, 2003

Instructions Supplier Request Form

Required Information:

Supplier Name: The official name of the supplier. This name will be used on printed checks, if the supplier is not paid via EFT and/or on 1099 or other IRS forms.

DUNS Number: The supplier’s DUNS number. If the supplier does not have a DUNS number, a supplier code will be assigned when the data is entered to the system.

Taxpayer ID: The supplier’s Taxpayer ID number (TIN or SSN).

Supplier Type: Federal is for federal government agency only. Non-Federal is for all other supplier types not specified (i.e. not an employee, not a non-employee traveler).

ALC (if Federal): Federal Agency’s ALC Trading Partner ID:

(if Federal)

Federal Agency’s Trading Partner ID

Mailing Address An address is required for all suppliers, even those paid via EFT. Enter the full address of the supplier: Street Address, City, State and Zip Code. If a foreign country, include Province and Postal Code as appropriate.

Bank Name The name of the supplier’s bank.

Bank Routing Number:

The routing number (ABA number) for EFT deposits to supplier’s bank.

Bank Account Number:

The supplier’s bank account number.

Checking/Savings: C – Checking, or S – Savings

Optional Information:

Alternate Name: This field is used for query or secondary reference purposes only. You may enter another name for this supplier; for example, when a company uses a DBA.

Telephone Number: The main telephone number for this supplier Contact Info: Name, Title and Telephone Number of supplier contact.

E-mail Address: The supplier e-mail address. This field may be used to send remittance advice information to the supplier via email (for clients who have selected to use this feature).