10. VA Form 10091 - FSC Vendor File Request.pdf
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- 36C24W26R0077
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VA-FSC VENDOR FILE REQUEST
FORM INSTRUCTIONS
NOTE:
Only completed forms signed by an “Authorized Representative” will be processed. Contact information for any questions / inquiries can be found on the form itself.
Purpose of Form:
VA Form 10091 is used to gather essential payment data from vendors (Commercial, Individuals, Veterans, etc.) to establish or update vendor records in order to process electronic payments in accordance with Title 31 of the Code of Federal Regulation Part 208 (31 CFR Part 208).
Request Type:
If this is the first time registering in our financial system for VA payments, please select NEW VENDOR otherwise choose UPDATE EXISTING VENDOR and complete Sections II, III and IV.
Section I: VA Facility Information (For Station Use Only):
1. Station Number:
3-digit number of VA Station that is submitting this form.
plus NCA, VHA, VBA.
2. Station Contact:
VA employee who completes, signs and submits this form.
3. Station Phone Number:
Direct number/extension for employee listed in Box 2.
4. Station Fax Number:
Fax number for office in Box 1.
5. Station Email Address:
The va.gov email for employee in Box 2.
6. Payee Vendor Type (Required):
The appropriate vendor type of the Payee/Vendor in Section II.
• F - Federal Vendor:
Include 2-digit Facts.
• O - Foreign Vendor:
Include W8Ben with foreign identification number
7. Miscellaneous Actions (If applicable):
• Assignment of Claims:
Use ONLY if employee in Box 2 is a Contracting Officer. Must include “Notice of Assignment” and “Instrument of Assignment” with completed form.
• LGY Vendor:
Loan Guaranty include 6-digit account number.
Section II: Payee/Vendor Information
* If you are a NEW VENDOR and registered in the System of Awards Management (SAM) with a Unique Entity Identifier (UEI) you MUST complete boxes 8 - 11; 14 - 19 plus Sections III and IV. Additionally, all information provided on the VA Form 10091 must match the information found in SAM or your request will not be processed.
If you are a NEW VENDOR and are NOT registered in SAM, you MUST complete boxes 11; 14 - 19 plus Sections III and IV.
If you are an EXISTING VENDOR and registered in SAM, any banking changes MUST be made in SAM. All other changes would still require an “Authorized Representative” to complete and sign the VA Form 10091.
8. Commercial Vendor registered in Sam.gov:
Check box if Payee/Vendor in Section II is registered in
SAM.
See * above for mandatory fields to be completed.
9. Unique Entity Identify (UEI):
The (12) character, alphanumeric data element assigned by SAM.gov.
10. EFT Indicator:
The unique 4-character code associated with UEI in Box
9. Blank or incorrect information in this field may cause a delay in processing your request.
11. SSN/TIN:
The 9-digit IRS identifier for the Payee/Vendor in Section II. Tax ID Numbers (TINs) are generally assigned to companies with employees. Employer Identification Number (EINs) are typically assigned to a business or entity (such as a corporation or an LLC. Individual Tax ID Numbers (ITINs) assigned to individuals required to file taxes but ineligible for a Social Security Number (SSN).
12. NPI:
A standard 10-digit unique identifier for medical providers only. Complete, if applicable.
13. SMALL BUSINESS:
Check box, if applicable.
14. PAYEE VENDOR NAME:
Legal name exactly as it appears on file with the Internal Revenue Service (IRS).
15. DOING BUSINESS AS (DBA):
If conducting business under another name, complete.
16. PAYEE/VENDOR EMAIL:
Email address for the person listed in Boxes 24 and 25.
17. PAYEE/VENDOR PHONE NUMBER:
Direct number and extension for the person listed in Boxes 24 and 25.
18. CURRENT ADDRESS:
Provide the address linked to the Payee/Vendor listed in Box 14 and where all official correspondence will be sent.
19. PREVIOUS ADDRESS (Required for address change requests):
Provide the address previously linked to the Payee/ Vendor listed in Box 14 and where all official correspondence has been sent.
VA FORM 10091, JAN 2024, page 1
Section III: EFT/ACH (Required IAW 31 CFR Part 208):
20. CURRENT BANK NAME:
Provide the name of the Financial Institution linked to the Payee/Vendor listed in Box 14 and where all payments for goods/services provided are sent.
21. CURRENT BANK 9-DIGIT ROUTING NUMBER:
The 9-digit number that identifies the bank listed in Box 20 as a member of the American Bankers Association (ABA). The routing number is usually found in the lower-left corner at the bottom of a check. Do NOT use a deposit slip routing number. This will result in a rejected payment.
22. CURRENT BANK ACCOUNT NUMBER:
The unique set of digits assigned by the Financial Institution in Box 20 to the account holder linked to the Payee/Vendor in Box 14.
23. CURRENT ACCOUNT TYPE:
Self-explanatory.
Section IV: Authorized Representative Title 18, United States Code, Section 1001 (18 U.S.C. 1001) makes it a crime to: 1) knowingly and willfully; 2) make any materially false, fictitious or fraudulent statement or representation; 3) in any matter within the jurisdiction of the executive, legislative or judicial branch of the United States.
24. NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:
For the purpose of VA Form 10091, an Authorized Representative is defined as: the actual Payee/Vendor listed in Box 14 OR an individual who is designated and authorized, in writing, to represent the Payee/Vendor listed in Box 14.
25. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
In signing this form, you certify that you have carefully read the foregoing instructions to complete this form and that you understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001).
VA FORM 10091, JAN 2024 Page 2
OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01-31-2027
VA-FSC VENDOR FILE REQUEST FORM
REQUEST TYPE
NEW VENDOR UPDATE EXISTING VENDOR
DATE (MM-DD-YYYY)
I. VA FACILITY INFORMATION (For Station Use Only)
1. STATION NUMBER
NCA VHA VBA
2. STATION CONTACT
3. STATION PHONE NUMBER 4. STATION FAX NUMBER
5. STATION EMAIL ADDRESS
6. PAYEE/VENDOR TYPE (Select one)
C - COMMERCIAL
C - ADMIN LOAN & ACCT
I - INDIVIDUAL
I - CAREGIVER
I - HONORARIUM
V - VETERAN
F - FEDERAL AGENCY
O - FOREIGN
A - AGENT CASHIER
U - UTILITY
C - MEDICAL PROVIDER
FACTS ID
7. MISCELLANEOUS ACTIONS (Select one)
WINRS ASSIGNMENT OF CLAIMS
(All applicable documents)
BILL OF COLLECTIONS SETTLEMENT/TORTS
LGY ACCOUNT #
II. PAYEE/VENDOR INFORMATION
8. COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)
9. UNIQUE ENTITY IDENTIFIER (UEI)
10. EFT IDENTIFER
11. SSN/TIN
12. NPI
13. SMALL BUSINESS - MUST BE QUALIFIED AS SMALL BUSINESS IN SAM
OR FURNISH SBA CONFIRMATION
14. PAYEE/VENDOR NAME
15. DOING BUSINESS AS (DBA)
16. PAYEE/VENDOR EMAIL ADDRESS
17. PAYEE/VENDOR PHONE NUMBER
18. CURRENT ADDRESS (Include Street, City, State and Zip Code)
19. PREVIOUS ADDRESS (Include Street, City, State and Zip Code)
III. EFT/ACH (Required IAW 31 CFR Part 208)
20. CURRENT BANK NAME
21. CURRENT BANK NINE-DIGIT ROUTING NUMBER
22. CURRENT BANK ACCOUNT NUMBER
23. CURRENT ACCOUNT TYPE
CHECKING SAVINGS
IV. AUTHORIZED REPRESENTATIVE
CERTIFICATION
In signing this form, you certify that you have carefully read the foregoing instructions to complete this form and that you understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 100).
24. NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
25. SIGNATURE OF AUTHORIZED REPRESENTATIVE
NORMAL PROCESSING TIME IS 15 - 30 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
VA-FSC CUSTOMER ENGAGEMENT:
PHONE: 1-877-353-9791
EMAIL: VAFSCCSHD@VA.GOV
FOR STATION INQUIRIES:
STATION CARE CENTER: 1-866-372-1141
PRIVACY ACT STATEMENT
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 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.
PAPERWORK REDUCTION ACT STATEMENT:
This information is collected in accordance with Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 15 minutes. This includes the time it will take to read instructions, gather the necessary facts, and fill out the form.
VA FORM
JAN 2024 10091
mailto:VAFSCCSHD@VA.GOV
VA-FSC VENDOR FILE REQUEST
FORM INSTRUCTIONS
NOTE:
Only completed forms signed by an “Authorized Representative” will be processed. Contact information for any questions / inquiries can be found on the form itself.
Purpose of Form:
VA Form 10091 is used to gather essential payment data from vendors (Commercial, Individuals, Veterans, etc.) to establish or update vendor records in order to process electronic payments in accordance with Title 31 of the Code of Federal Regulation Part 208 (31 CFR Part 208).
Request Type:
If this is the first time registering in our financial system for VA payments, please select NEW VENDOR otherwise choose UPDATE EXISTING VENDOR and complete Sections II, III and IV.
Section I: VA Facility Information (For Station Use Only):
1. Station Number:
3-digit number of VA Station that is submitting this form. plus NCA, VHA, VBA.
2. Station Contact:
VA employee who completes, signs and submits this form.
3. Station Phone Number:
Direct number/extension for employee listed in Box 2.
4. Station Fax Number:
Fax number for office in Box 1.
5. Station Email Address:
The va.gov email for employee in Box 2.
6. Payee Vendor Type (Required):
The appropriate vendor type of the Payee/Vendor in Section II.
F - Federal Vendor:
Include 2-digit Facts.
O - Foreign Vendor:
Include W8Ben with foreign identification number
7. Miscellaneous Actions (If applicable):
Assignment of Claims:
Use ONLY if employee in Box 2 is a Contracting Officer. Must include “Notice of Assignment” and “Instrument of Assignment” with completed form.
LGY Vendor:
Loan Guaranty include 6-digit account number.
Section II: Payee/Vendor Information
* If you are a NEW VENDOR and registered in the System of Awards Management (SAM) with a Unique Entity Identifier (UEI) you MUST complete boxes 8 - 11; 14 - 19 plus Sections III and IV. Additionally, all information provided on the VA Form 10091 must match the information found in SAM or your request will not be processed.
If you are a NEW VENDOR and are NOT registered in SAM, you MUST complete boxes 11; 14 - 19 plus Sections III and IV.
If you are an EXISTING VENDOR and registered in SAM, any banking changes MUST be made in SAM. All other changes would still require an “Authorized Representative” to complete and sign the VA Form 10091.
8. Commercial Vendor registered in Sam.gov:
Check box if Payee/Vendor in Section II is registered in SAM.
See * above for mandatory fields to be completed.
9. Unique Entity Identify (UEI):
The (12) character, alphanumeric data element assigned by SAM.gov.
10. EFT Indicator:
The unique 4-character code associated with UEI in Box 9. Blank or incorrect information in this field may cause a delay in processing your request.
11. SSN/TIN:
The 9-digit IRS identifier for the Payee/Vendor in Section II. Tax ID Numbers (TINs) are generally assigned to companies with employees. Employer Identification Number (EINs) are typically assigned to a business or entity (such as a corporation or an LLC. Individual Tax ID Numbers (ITINs) assigned to individuals required to file taxes but ineligible for a Social Security Number (SSN).
12. NPI:
A standard 10-digit unique identifier for medical providers only. Complete, if applicable.
13. SMALL BUSINESS:
Check box, if applicable.
14. PAYEE VENDOR NAME:
Legal name exactly as it appears on file with the Internal Revenue Service (IRS).
15. DOING BUSINESS AS (DBA):
If conducting business under another name, complete.
16. PAYEE/VENDOR EMAIL:
Email address for the person listed in Boxes 24 and 25.
17. PAYEE/VENDOR PHONE NUMBER:
Direct number and extension for the person listed in Boxes 24 and 25.
18. CURRENT ADDRESS:
Provide the address linked to the Payee/Vendor listed in Box 14 and where all official correspondence will be sent.
19. PREVIOUS ADDRESS (Required for address change requests):
Provide the address previously linked to the Payee/Vendor listed in Box 14 and where all official correspondence has been sent.
VA FORM 10091, JAN 2024, page 1 V A Form 10091, JANUARY 2024 Section III: EFT/ACH (Required IAW 31 CFR Part 208):
20. CURRENT BANK NAME:
Provide the name of the Financial Institution linked to the Payee/Vendor listed in Box 14 and where all payments for goods/services provided are sent.
21. CURRENT BANK 9-DIGIT ROUTING NUMBER:
The 9-digit number that identifies the bank listed in Box 20 as a member of the American Bankers Association (ABA). The routing number is usually found in the lower-left corner at the bottom of a check. Do NOT use a deposit slip routing number. This will result in a rejected payment.
22. CURRENT BANK ACCOUNT NUMBER:
The unique set of digits assigned by the Financial Institution in Box 20 to the account holder linked to the Payee/Vendor in Box 14.
23. CURRENT ACCOUNT TYPE:
Self-explanatory.
Section IV: Authorized Representative Title 18, United States Code, Section 1001 (18 U.S.C. 1001) makes it a crime to: 1) knowingly and willfully; 2) make any materially false, fictitious or fraudulent statement or representation; 3) in any matter within the jurisdiction of the executive, legislative or judicial branch of the United States.
24. NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:
For the purpose of VA Form 10091, an Authorized Representative is defined as: the actual Payee/Vendor listed in Box 14 OR an individual who is designated and authorized, in writing, to represent the Payee/Vendor listed in Box 14.
25. SIGNATURE OF AUTHORIZED REPRESENTATIVE:
In signing this form, you certify that you have carefully read the foregoing instructions to complete this form and that you understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001).
VA FORM 10091, JAN 2024
V A Form 10091, JANUARY 2024 OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01-31-2027 O M B Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01-31-2027 Department of Veterans Affairs logo
VA-FSC VENDOR FILE REQUEST FORM
V A-F S C VENDOR FILE REQUEST FORM
REQUEST TYPE
DATE (MM-DD-YYYY)
I. VA FACILITY INFORMATION (For Station Use Only)
1. STATION NUMBER
2. STATION CONTACT
3. STATION PHONE NUMBER
4. STATION FAX NUMBER
5. STATION EMAIL ADDRESS
6. PAYEE/VENDOR TYPE (Select one)
FACTS ID
7. MISCELLANEOUS ACTIONS (Select one)
II. PAYEE/VENDOR INFORMATION
9. UNIQUE ENTITY IDENTIFIER (UEI)
10. EFT IDENTIFER
11. SSN/TIN
12. NPI
MUST BE QUALIFIED AS SMALL BUSINESS IN SAM OR FURNISH SBA CONFIRMATION
14. PAYEE/VENDOR NAME
15. DOING BUSINESS AS (DBA)
16. PAYEE/VENDOR EMAIL ADDRESS
17. PAYEE/VENDOR PHONE NUMBER
18. CURRENT ADDRESS (Include Street, City, State and Zip Code)
19. PREVIOUS ADDRESS (Include Street, City, State and Zip Code) III. EFT/ACH (Required IAW 31 CFR Part 208)
20. CURRENT BANK NAME
21. CURRENT BANK NINE-DIGIT ROUTING NUMBER
22. CURRENT BANK ACCOUNT NUMBER
23. CURRENT ACCOUNT TYPE
IV. AUTHORIZED REPRESENTATIVE
CERTIFICATION
In signing this form, you certify that you have carefully read the foregoing instructions to complete this form and that you understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 100).
24. NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
25. SIGNATURE OF AUTHORIZED REPRESENTATIVE
NORMAL PROCESSING TIME IS 15 - 30 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
VA-FSC CUSTOMER ENGAGEMENT:
PHONE: 1-877-353-9791
EMAIL: VAFSCCSHD@VA.GOV
FOR STATION INQUIRIES:
STATION CARE CENTER: 1-866-372-1141
PRIVACY ACT STATEMENT
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 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.
PAPERWORK REDUCTION ACT STATEMENT:
This information is collected in accordance with Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 15 minutes. This includes the time it will take to read instructions, gather the necessary facts, and fill out the form.
VA FORM
JAN 2024
V A FORM 10091, JANUARY 2024
10091 VA Form 10091, VA - FSC VENDOR FILE REQUEST FORM
FSC, VENDOR, FILE, 10091
Valerie Robinson/Yolanda Ramos/Nicholas Kerrigan
FSC/047
Missie Vaccaro-Palomaki
JANUARY 2024
July 2016
| NEW radio button: |
| UPDATE radio button: |
| DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| I. V A FACILITY INFORMATION. (For Station Use Only) |
1. STATION NUMBER.:
| V B A Radio Button: |
| 2. STATION CONTACT.: |
| 3. STATION PHONE NUMBER.: |
| 4. STATION FAX NUMBER.: |
| 5. STATION EMAIL ADDRESS.: |
| SAVINGS radio button: 0 |
| FACTS I D. 2 characters max.: |
| L G Y ACCOUNT NUMBER. 6 characters max.: |
| II. PAYEE / VENDOR INFORMATION. |
8. COMMERCIAL VENDOR REGISTERED IN SAM.GOV (Required I A. W F A. R 4.1102). check box: 0
| 9. UNIQUE ENTITY IDENTIFIER (U E I). 12 characters max.: |
| 10. E F T IDENTIFER: |
| 11. SOCIAL SECURITY NUMBER / T I N. 9 characters max.: |
| 12. N P I. 10 characters max.: |
| 14. PAYEE / VENDOR NAME.: |
| 15. DOING BUSINESS AS (D B A): |
| 16. PAYEE/VENDOR EMAIL ADDRESS.: |
| 17. PAYEE/VENDOR PHONE NUMBER.: |
| 18. CURRENT ADDRESS (Include Street, City, State and Zip Code).: |
| 19. PREVIOUS ADDRESS (Include Street, City, State and Zip Code).: |
| III. E F T / A C H (Required I A. W 31 C F R Part 208). |
20. CURRENT BANK NAME.:
| 21. CURRENT BANK NINE-DIGIT ROUTING NUMBER. Enter 9 digit number.: |
| 22. CURRENT BANK ACCOUNT NUMBER. 17 characters max.: |
| 24. NAME AND TITLE OF AUTHORIZED REPRESENTATIVE: |
| 25. SIGNATURE OF AUTHORIZED REPRESENTATIVE. This is a digital signature field. |
NORMAL PROCESSING TIME IS 15 - 30 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES:
File details come from the government source that posted it. Updated .