VA10091.pdf
PDF 90 KB Posted
- Attached to
- J035--AIR TESTING AND CERTIFICATION SERVICES Federal contract opportunity
- Solicitation number
- 36C26226Q1235
About this file
This is the VA-FSC Vendor File Request Form (VA Form 10091), a registration and enrollment document used by the U.S. Department of Veterans Affairs to establish or update vendor records in its Financial Management System (FMS). The form is designed for vendors seeking to do business with the VA and requires submission via secure fax to 512-460-5221 with normal processing time of 3-5 business days.
The form collects comprehensive vendor information organized into three main sections: VA Facility Information (including station number and contact details), Payee/Vendor Information (including vendor type classification, business registration status, and authorized representative details), and EFT/ACH banking information required by 31 CFR Part 208. Key required fields include the vendor's legal name as filed with the IRS, Unique Entity Identifier (UEI) if registered in SAM.gov, Social Security Number or Tax Identification Number, current and previous addresses, bank name, nine-digit routing number, and account number. The form also accommodates special vendor categories such as federal agencies, foreign vendors, medical providers (requiring NPI numbers), small businesses, employees, individuals, veterans, and utility companies. Optional sections address miscellaneous actions including assignment of claims, bill of collections settlements, and LGY account assignments. A handwritten signature from an authorized representative is mandatory, and caregivers and veterans are exempted from email address requirements. The form is subject to the Privacy Act of 1974 and requires an average of 15 minutes to complete.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| S06 36C26226Q1235 0001-Site Visit.docx | DOCX document | |
| W-9 Form.pdf | ||
| S02 - RFQ 36C26226Q1235 - Air Testing.pdf | ||
| FMS Vendor File Update Request Form.pdf | ||
| 36C26226Q1235_2.docx | DOCX document |
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Text version
OMB Approved No. 2900-0846 Respondent Burden: 15 Minutes Expiration Date: 01-31-2024
VA-FSC VENDOR FILE REQUEST FORM
NEW UPDATE
DATE (MM-DD-YYYY)
VA FACILITY INFORMATION
STATION NUMBER
NCA VHA VBA
STATION CONTACT
STATION PHONE NUMBER STATION FAX NUMBER
STATION EMAIL ADDRESS
PAYEE/VENDOR TYPE (Select one)
C - COMMERCIAL/ALAC
E - EMPLOYEE
I - INDIVIDUAL/HONORARIUM
V - VETERAN
CAREGIVER
F - FEDERAL AGENCY
O - FOREIGN
A - AGENT CASHIER
U - UTILITY
MEDICAL PROVIDER
FACTS ID
MISCELLANEOUS ACTIONS (Select one)
WINRS ASSIGNMENT OF CLAIMS
(All applicable documents)
BILL OF COLLECTIONS SETTLEMENT/TORTS
LGY ACCOUNT #
PAYEE/VENDOR INFORMATION
COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)
UNIQUE ENTITY IDENTIFIER (UEI)
EFT IDENTIFER
SSN/TIN
NPI
SMALL BUSINESS - PAYEE/VENDOR MUST BE QUALIFIED AS SMALL
BUSINESS IN SAM OR FURNISH SBA CONFIRMATION
PAYEE/VENDOR NAME
DBA
AUTHORIZED REPRESENTATIVE NAME
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 AUTHORIZED REPRESENTATIVE
SIGNATURE OF AUTHORIZED REPRESENTATIVE
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
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
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
MAR 2022 10091 Page 1
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. Payee/Vendor Type - Check the appropriate Payee/Vendor Type box. REQUIRED
9. Miscellaneous Actions - Check the appropriate Payee/Vendor 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.
Payee/Vendor Information
9. Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management (SAM) with UEI Identifier check this box.
10. UEI # - Unique Entity Identifier is (12) character, alphanumeric data element assigned by SAM.gov.
IF REGISTERED IN SYSTEM OF AWARDS MANAGEMENT - REQUIRED
11. EFT INDICATOR - Electronic Funds Transfer Indicator used to identify additional bank accounts associated with a single SAM.gov registration. 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. Authorized Representative Name - Name of Person authorized to make changes on the payee/vendor's behalf. REQUIRED
18. Email - Authorized Representative email address. REQUIRED (Caregivers/Veterans exempted if no email address.)
19. Phone - Authorized Representative 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 Authorized Representative - Printed Name. REQUIRED
27. Signature of Authorized Representative - 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 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.
VA FORM 10091, MAR 2022 Page 2
File details come from the government source that posted it. Updated .