Itin Details

The VA Form 10091, also known as the "Statement of Service," is a document that veterans use to provide information about their military service. This form can be used to apply for benefits, request medals and other recognition, or to update their contact information with the VA. The Statement of Service must be completed properly in order to ensure that all necessary information is available for the VA. Veterans should carefully review the instructions on how to complete this form before submitting it.

The listing features details about the va form 10091. You might like to read it before filling out the gaps.

QuestionAnswer
Form NameVa Form 10091
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

OMB Approved No. 2900-0846

Respondent Burden: 15 Minutes

Expiration Date: 01-31-2024

 

 

 

 

 

 

 

 

 

 

 

 

 

VA-FSC VENDOR FILE REQUEST FORM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEW

 

 

 

 

 

 

 

 

 

 

UPDATE

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

I - INDIVIDUAL/HONORARIUM

 

 

A - AGENT CASHIER

 

 

 

 

 

 

BUSINESS IN SAM OR FURNISH SBA CONFIRMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA-FSC CUSTOMER SERVICE HELP DESK:

 

 

 

 

CURRENT ADDRESSS (Include Street, City, State and Zip Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE: 512-460-5380

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMAIL: VAFSCCSHD@VA.GOV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR ALL OTHER INQUIRIES:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUSTOMER CARE CENTER: 1-877-353-9791

 

 

 

 

PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

Clearing House Payment System.

 

SIGNATURE OF PAYEE/VENDOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES

VA FORM 10091

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.