D.2 - VA_Form_10091_FMS_Vendor_File_Request_Form.pdf
PDF 758 KB Posted
- Attached to
- S208--Landscaping & Irrigation Services Federal contract opportunity
- Solicitation number
- 36C26222R0101
About this file
This document is a vendor file request form used by the Department of Veterans Affairs (VA) to collect information from potential vendors. The form requests contact, address, and banking information to establish vendors in the VA's payment system. Required fields include vendor name, address, Taxpayer Identification Number, and signature. It also collects optional information such as DUNS number and small business status. The form instructs vendors to submit all documentation via secure fax to the listed number to initiate VA's vendor onboarding process, which takes three to five business days. No products or services are specified in this vendor form template.
This opportunity is a request for proposal from the VA's Greater Los Angeles Healthcare System for landscaping, irrigation maintenance, and repair services. The solicitation number is 36C26222R0101 and involves the Veterans Health Administration and Veterans Integrated Service Network 22. The RFP provides an opportunity for vendors to bid on recurring landscaping and irrigation services but does not include pricing terms. The response deadline is not specified. The opportunity is for a pre-solicitation phase with no incumbent listed. Services required include landscaping and irrigation maintenance at VA facilities in the Greater Los Angeles area.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| RFP 36C26222R0101 Amendment 0002 GLA Landscaping.pdf | ||
| RFP 36C26222R0101 - 0001 Amendment.pdf | ||
| RFP 36C26222R0101 - 0001 Amendment.pdf | ||
| RFP 36C26222R0101 0001 Amendment.pdf | ||
| RFP 36C26222R0101 0001 Questions.pdf | ||
| D.3 - VA NOTICE OF LIMITATIONS ON SUBCONTRACTING—CERTIFICATE OF COMPLIANCE FOR SERVICES AND CONSTRUCTION.pdf | ||
| 36C26222R0101.docx | DOCX document | |
| RFP 36C26222R0101 - VAGLA Landscape _ Irrigation.pdf |
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Text version
OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 07-31-2019
VA-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 - PAYEE/VENDOR MUST BE QUALIFIED AS SMALL
BUSINESS IN SAM OR FURNISH SBA CONFIRMATION
PAYEE/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
NAME AND TITLE OF PAYEE/VENDOR
SIGNATURE OF PAYEE/VENDOR
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
VA-FSC CUSTOMER SERVICE HELP DESK:
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
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.
VA FORM
SEP 2017 10091
mailto:VAFSCCSHD@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 - USE ONLY IF ALAC include the 6 digit account number
· Assignment of Claims- USE ONLY IF ASSIGNMENT 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 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 EFT/ACH (REQUIRED IAW 31CFR Part 208)
21. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED
22. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number)
REQUIRED
23. US. Account # - Provide bank account number maximum 17 digits REQUIRED
24. Account Type - Check appropriate box that is associated with account number provide above REQUIRED
25. Name & Title of Payee/Vendor - REQUIRED
26. Signature of Payee/Vendor - 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 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.
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 OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
www.reginfo.gov/public/do/PRAMain
OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 07-31-2019 O M B Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 07-31-2019 \\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs logo
VA-FSC VENDOR FILE REQUEST FORM
V A-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
PAYEE/VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN SAM OR FURNISH SBA CONFIRMATION
PAYEE/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
NAME AND TITLE OF PAYEE/VENDOR
SIGNATURE OF PAYEE/VENDOR
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
VA-FSC CUSTOMER SERVICE HELP DESK:
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
FOR QUESTIONS REGARDING THIS FORM:
N V F CONTACT INFORMATION:
VA-FSC CUSTOMER SERVICE HELP DESK:
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
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.
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.
VA FORM
SEP 2017
V A FORM 1 0 0 9 1, SEPTEMBER 2017
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.
Instructions for F M S Vendor File Request Form
1. NEW box option - Check box if you are a new vendor not in the F M S system.
2. UPDATE box option - Check box if you are an existing vendor in the FMS system.
2. UPDATE box option - Check box if you are an existing vendor in the F M S 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 V A Facility Information
3. Station # - This portion pertains to the V A 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
4. Station Contact Name - V A Station employee. FOR STATION USE ONLY
5. Station Phone - VA Station employee direct number. FOR STATION USE ONLY
5. Station Phone - V A Station employee direct number. FOR STATION USE ONLY
6. Station Fax Number - VA Station fax number. FOR STATION USE ONLY
6. Station Fax Number - V A Station fax number. FOR STATION USE ONLY
7. Station Email - VA Station employee work email address. FOR STATION USE ONLY
7. Station Email - V A 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 - USE ONLY IF ALAC include the 6 digit account number
· Assignment of Claims- USE ONLY IF ASSIGNMENT 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 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 - USE ONLY IF ALAC include the 6 digit account number
· Assignment of Claims- USE ONLY IF ASSIGNMENT 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 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 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
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
10. DUNS+4 - If you have more than one E F T 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
11. S S N/T I N - The Social Security Number (S S N) is the nine-digit number. The Tax Identification Number (T I N) is the nine-digit number which is either an Employer Identification Number (E I N); complete this section with S S N, T I N, E I N or I T I N. REQUIRED
12. NPI - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL
12. N P I - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL
13. Small Business - Check box 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
14. Vendor Name - Provide legal name as it is on file with the I R S REQUIRED
15. DBA - Doing Business As name complete if applicable OPTIONAL
15. D B A - Doing Business As name complete if applicable OPTIONAL
16. Contact - Name of Point of Contact if additional information is required OPTIONAL
16. Contact - Name of Point of Contact if additional information is required OPTIONAL
17. Email - Point of Contact email address OPTIONAL
17. Email - Point of Contact email address OPTIONAL
18. Phone - Point of Contact phone number OPTIONAL
18. Phone - Point of Contact phone number OPTIONAL
19. Current Address - Provide your most current address, city, state & zip code REQUIRED
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
20. Previous Address - Provide previous address, city, state and zip code REQUIRED FOR ADDRESS CHANGES EFT/ACH (REQUIRED IAW 31CFR Part 208)
21. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED E F T/A C H (REQUIRED IAW 31C F R Part 208)
21. US. Bank Name - provide financial institution name city, state & zip code. REQUIRED
22. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number) REQUIRED
22. U. S. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number) REQUIRED
23. US. Account # - Provide bank account number maximum 17 digits REQUIRED
23. U. S. Account # - Provide bank account number maximum 17 digits REQUIRED
24. Account Type - Check appropriate box that is associated with account number provide above REQUIRED
24. Account Type - Check appropriate box that is associated with account number provide above REQUIRED
25. Name & Title of Payee/Vendor - REQUIRED
25. Name & Title of Payee/Vendor - REQUIRED
26. Signature of Payee/Vendor - REQUIRED
Please fax the completed form to 512-460-5221 for processing.
26. Signature of Payee/Vendor - 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 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.
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 OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
PRIVACY ACT NOTICE: The following information is provided to comply with the Privacy Act of 19 74 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 C F R 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 V A Vendor Record. 31 U.S.C. 3322 and 31 C F R 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 O M B control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid O M B control numbers can be located on the O M B Internet Page at www.reginfo.gov/public/do/PRAMain.
Tammy Bailey/Valerie Robinson Missie Vaccaro-Palomaki VA Form 10091, FSC VENDOR FILE REQUEST FORM
SEPTEMBER 2017
JULY 2016
10091, FSC, VENDOR, FILE
| "NEW" CHECKBOX: 0 |
| V A FACILITY INFORMATION: STATION NUMBER: |
| SIGNATURE OF PAYEE/VENDOR. |
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES:
| ACCOUNT NUMBER LINE 2 OF 2: |
| ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0 |
| ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0 |
| ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0 |
| "UPDATE" CHECKBOX: 0 |
| Date: |
| PAYEE/VENDOR INFORMATION: COMMERCIAL VENDOR REGISTERED IN SAM.GOV (Required IAW FAR 4.1102) CHECKBOX: 0 |
File details come from the government source that posted it. Updated .