VA Form 10091 Fsc Vendor File Request Form

What Is VA Form 10091?

The VA Form 10091, FSC Vendor File Request Form is a document that contains all information necessary to create or update the Financial Management System (FMS) Vendor File.

The latest version of the form was released by the Department of Veterans Affairs (VA) in September 2017. An up-to-date fillable version of the VA Form 10091 is available for digital filing and download below or can be found on the VA website.

Vendor file is a paper or electronic file that includes important data on a vendor, e.g. specification documents, contracts, agreements, or warranty documentation. This information is necessary for receiving the VA payments according to the 1996 Debt Collection Improvement Act.

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OMB Approved No. 2900-0846
Respondent Burden: 15 Minutes
Expiration Date: 07-31-2019
VA-FSC VENDOR FILE REQUEST FORM
DATE
NEW
UPDATE
VA FACILITY INFORMATION
PAYEE/VENDOR INFORMATION
STATION NUMBER
COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)
STATION CONTACT
DUNS NUMBER
STATION PHONE NUMBER
STATION FAX NUMBER
DUNS+4
STATION EMAIL ADDRESS
SSN/TIN
PAYEE/VENDOR TYPE (Select one)
NPI
C - COMMERCIAL
F - FEDERAL AGENCY
E - EMPLOYEE
O - FOREIGN
FACTS ID
SMALL BUSINESS - PAYEE/VENDOR MUST BE QUALIFIED AS SMALL
BUSINESS IN SAM OR FURNISH SBA CONFIRMATION
I - INDIVIDUAL/HONORARIUM
A - AGENT CASHIER
PAYEE/VENDOR NAME
V - VETERAN
U - UTILITY
MISCELLANEOUS ACTIONS (Select one)
DBA
WINRS
ASSIGNMENT (All applicable documents)
BILL OF COLLECTIONS
SETTLEMENT/TORTS
CONTACT
ALAC/LGY ACCOUNT #
EMAIL ADDRESS
PHONE NUMBER
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
CURRENT ADDRESSS (Include Street, City, State and Zip Code)
VA-FSC CUSTOMER SERVICE HELP DESK:
PHONE: 512-460-5380
EMAIL:
VAFSCCSHD@VA.GOV
FOR ALL OTHER INQUIRIES:
PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)
CUSTOMER CARE CENTER: 1-877-353-9791
STATION CARE CENTER: 1-866-372-1141
SUBMIT ALL DOCUMENTATION VIA:
SECURE FAX: 512-460-5221
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
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
ACCOUNT TYPE
210. This information will be used by the Treasury Department to
CHECKING
SAVINGS
transmit payment data, by electronic means to vendor's financial
NAME AND TITLE OF PAYEE/VENDOR
institution. Failure to provide the requested information may delay
or prevent the receipt of payments through the Automated
SIGNATURE OF PAYEE/VENDOR
Clearing House Payment System.
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
10091
VA FORM
SEP 2017
OMB Approved No. 2900-0846
Respondent Burden: 15 Minutes
Expiration Date: 07-31-2019
VA-FSC VENDOR FILE REQUEST FORM
DATE
NEW
UPDATE
VA FACILITY INFORMATION
PAYEE/VENDOR INFORMATION
STATION NUMBER
COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)
STATION CONTACT
DUNS NUMBER
STATION PHONE NUMBER
STATION FAX NUMBER
DUNS+4
STATION EMAIL ADDRESS
SSN/TIN
PAYEE/VENDOR TYPE (Select one)
NPI
C - COMMERCIAL
F - FEDERAL AGENCY
E - EMPLOYEE
O - FOREIGN
FACTS ID
SMALL BUSINESS - PAYEE/VENDOR MUST BE QUALIFIED AS SMALL
BUSINESS IN SAM OR FURNISH SBA CONFIRMATION
I - INDIVIDUAL/HONORARIUM
A - AGENT CASHIER
PAYEE/VENDOR NAME
V - VETERAN
U - UTILITY
MISCELLANEOUS ACTIONS (Select one)
DBA
WINRS
ASSIGNMENT (All applicable documents)
BILL OF COLLECTIONS
SETTLEMENT/TORTS
CONTACT
ALAC/LGY ACCOUNT #
EMAIL ADDRESS
PHONE NUMBER
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
CURRENT ADDRESSS (Include Street, City, State and Zip Code)
VA-FSC CUSTOMER SERVICE HELP DESK:
PHONE: 512-460-5380
EMAIL:
VAFSCCSHD@VA.GOV
FOR ALL OTHER INQUIRIES:
PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)
CUSTOMER CARE CENTER: 1-877-353-9791
STATION CARE CENTER: 1-866-372-1141
SUBMIT ALL DOCUMENTATION VIA:
SECURE FAX: 512-460-5221
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
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
ACCOUNT TYPE
210. This information will be used by the Treasury Department to
CHECKING
SAVINGS
transmit payment data, by electronic means to vendor's financial
NAME AND TITLE OF PAYEE/VENDOR
institution. Failure to provide the requested information may delay
or prevent the receipt of payments through the Automated
SIGNATURE OF PAYEE/VENDOR
Clearing House Payment System.
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
10091
VA FORM
SEP 2017
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.

Download VA Form 10091 Fsc Vendor File Request Form

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What Is VA Form 10091 Used for?

The VA 10091 form is used by vendors in order to provide the Department of Veterans Affairs - Financial Services Center (VA-FSC) the data required for the creation or modifying their VA vendor record. The information entered in this document is used by the Treasury Department to transmit payment data to the vendor's financial institution by electronic means. If the requested information is not provided by the vendor, it may affect the receipt of the payment through the Automated Clearing House Payment System.

VA Form 10091 Instructions

Filing instructions are provided on the second page of the document. The detailed description of how to fill out the form can be found below. It usually takes about 15 minutes to look through the instructions, to find the required information, and to complete the VA 10091.

How to Fill out VA Form 10091?

The VA 10091 form should be completed as follows:

  1. If you are a new vendor in the FMS system, check "New" box. In order to update an already existing file, check "Update" box;
  2. VA Facility Information part has to contain 3 digit station number, VA Station employee name, direct phone number, email address, and fax number. These fields should be completed by the VA Station;
  3. Choose the applicable type of payee/vendor in the "Payee/Vendor Type" section;
  4. Section "Miscellaneous Actions" is optional. It includes a list of boxes. Check only one of them;
  5. If you are registered in System of Awards Management, check the applicable box in the right part of the document;
  6. In "Data Universal Numbering System (DUNS) Number" field, indicate a unique 9-digit number administered by Dun and Bradstreet. This part is optional;
  7. Complete "DUNS+4" field only if you have more than one Electronic Funds Transfer (EFT) account number;
  8. Enter 9-digit Social Security number (SSN), Tax Identification Number (TIN), or Employer Identification Number in the section "SSN/TIN";
  9. "NPI" field is for 10-digit identifiers for health care providers;
  10. If you are qualified as Small Business, check the applicable box;
  11. Provide your legal name in the box "Vendor Name". You can find it on the file with the Internal Revenue Service;
  12. "DBS" (Doing Business As) field is optional;
  13. If additional information is required, the fields "Contact", "Email", and "Phone" should be completed (box "Contact" should contain the Point of Contact name). Otherwise, this part may be left blank.
  14. Indicate the most current address, including city, state, and zip code in field "Current Address";
  15. If you upgrade your record and want to change the address, indicate the previous address in full, including zip code, city, and state in box "Previous Address";
  16. The last six fields are obligatory for all vendors;
  17. Enter the name of the financial institution in box "Bank Name". Provide its address, including city, state, and zip code in "Bank Address" field;
  18. Enter the routing number from the check-in box "Nine-Digit Bank Routing Number". Remember, that you are not allowed to enter Deposit slip routing number here;
  19. Specify the bank account number in the next box. The number should not exceed 17 digits;
  20. Indicate the account type by ticking the applicable checkbox below "Account Number" box;
  21. Provide your name and title in the next box.

Sign the form in the appropriate field. You may use a personal electronic signature for this purpose. Fax the completed 10091 VA form to 512-460-5221. It normally takes about 3 to 5 business days to process the request.

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