Form Va-Fsc - Vendor File Request

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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

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