VA Form 10091, FSC VENDOR FILE REQUEST FORM 10091, FSC, VENDOR, FILE 2025

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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.
Department of Veterans Affairs. Evidence Intake Center. PO Box 4444. Janesville, WI 53547-4444.
The memo should list all the Payee Account Numbers (PANS) that are affected. Send to: Regular Mail Only. HHS/PSC/Division of Payment Management, Post Office Box 6021, Rockville, MD 20852. Express Mail Only. HHS/PSC/Division of Payment Management, 7700 Wisconsin Avenue, Suite 920, Bethesda, MD 20814.
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.
After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. Show your monthly living expenses, including any monthly installment payments. If you do not have expenses from a particular source, write 0 or none in the space provided.
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