VA Form 10091 FSC Vendor File Request Form

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 tofill 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.