Attachment- A_ VA Form 10091-New 2021.pdf

0MB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01 -31 -2024

,1A I e US.Department Vft of Veterans Affa irs VA-FSC VENDOR FILE REQUEST FORM

□ NEW

VA FACILITY INFORMATION

STATION NUMBER

STATION CONTACT

STATION PHONE NUMBER

STATION EMAIL ADDRESS

PAYEENENDOR TYPE (Select one)

□ C - COMMERCIAUALAC

□ E - EMPLOYEE

□ I - INDIVIDUAUHONORARIUM

□ V-VETERAN

□ CAREGIVER

STATION FAX NUMBER

□ F - FEDERAL AGENCY

FACTS ID I I I

□ O-FOREIGN

□ A - AGENT CASHIER

□ U-UTILITY

□ MEDICAL PROVIDER

MISCELLANEOUS ACTIONS (Select one)

□ WINRS □ ASSIGNMENT OF CLAIMS

(All applicable documents)

□ BILL OF COLLECTIONS □ SETTLEMENT/TORTS

□ LGY ACCOUNT#

FOR QUESTIONS REGARDING THIS FORM:

NVF CONTACT INFORMATION:

VA-FSC CUSTOMER ENGAGEMENT:

PHONE: 512-460-5380

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

□ UPDATE

DATE (MM-DD-YYY}'.)

PAYEENENDOR INFORMATION

□ COMMERCIAL VENDOR REGISTERED IN SAM.GOV

(Required !AW FAR 4.1102)

DUNS NUMBER

DUNS+4

SSN/TIN

NPI

□ SMALL BUSINESS- PAYEENENDOR MUST BE QUALIFIED AS SMALL

BUSINESS IN SAM OR FURNISH SBA CONFIRMATION

PAYEENENDOR NAME

OBA

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 JAW 31 CFR Part 208)

BANK NAME

BANK ADDRESSS (Include City, State and Zip Code)

NINE-DIGIT BANK ROUTING NUMBER

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 l-=A=c=c=o::!::u=N=T=N=U=M=B=E::::!R=============::::!.,_--------1 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.

ACCOUNT TYPE

□ CHECKING □ SAVINGS

NAME AND TITLE OF PAYEENENDOR

SIGNATURE OF PAYEENENDOR

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

VA FORM

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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

8. PayeeNendor Type - Check the appropriate PayeeNendor Type box. REQUIRED

9. Miscellaneous Actions - Check the appropriate PayeeNendor Type box, some additional documentation required. OPTIONAL

• LGY Vendors - USE ONLY IF LGY. Include the 6 digit account number.

• Assignment of Claims - USE ONLY IF CONTRACTING OFFICER. 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.

PayeeN endor Information

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

REQUIRED

I 0. DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B).

IF REGISTERED IN SYSTEM OF A WARDS MANAGEMENT - REQUIRED

11. 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

12. 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

13. NPI - A standard 10 digit unique identifiers for medical providers only, complete this section if applicable.

MEDICAL PROVIDERS ONLY - REQUIRED

14. Small Business - Check box if applicable. OPTIONAL

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

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

17. Contact - Name of Point of Contact if additional information is required. REQUIRED

18. Email- Point of Contact email address. REQUIRED (CaregiversNeterans exempted ifno email address.)

19. Phone - Point of Contact phone number. REQUIRED

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

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

EFT/ACH (REQUIRED IAW 31CFR Part 208)

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

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

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

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

26. Name & Title of PayeeNendor - Printed Name. REQUIRED

27. Signature of PayeeNendor - HANDWRITTEN SIGNATURE 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 of31 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 0MB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid 0MB control numbers can be located on the 0MB Internet Page at www.reginfo.gov/public/do/PRAMain.

VA FORM 10091, AUG 2021 Page2