Vendor code information worksheet (Internal Use Only) fsh 6509. 11K, § 56. 16




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USDA Forest Service FS-6500-231 (08/2006)

VENDOR CODE INFORMATION WORKSHEET

(Internal Use Only)

FSH 6509.11K, § 56.16

The information on this form is requested under the provisions of 31 U.S.C. 3325 and 31 U.S.C 3332, for the purpose of disbursing Federal money. Disclosure of the information is mandatory; failure to furnish information will delay payment. See instructions on Page 2.

Section A. Vendor Information

1. Taxpayer Identification No.

2. DUNS+4

3. Vendor Code (for Updates)

     

     

     

4. Name

5. Contact Name

     

     

6. Address

7. Contact Phone Number

     

     

8. City

9. State

10. Zip Code+4

     

  

     

Section B. Banking Information for Electronic Funds Transfer

1.  EFT Information is provided below

 EFT Information is not needed because one or more of the below criteria apply:

 DUNS+4 is provided above and vendor is registered in CCR

 One-time payment request

 Payee is in a foreign country

 Vendor transactions are limited to Billings & Collections (if no refund will be processed)

 Vendor transactions are limited to Billings & Collections (if refund will be processed)

 Request re-activation of inactive vendor code for obligation modification only



 Request re-activation of inactive vendor code for final payment

 Payee has signed waiver statement in Section E



2. Bank Name

     

3. Bank City

4. Bank State

5. Bank Zip Code+4

     

     

     

6. ABA Routing Number

7. Account Number

8. Type of Account

     

     

 Checking

 Savings



Section C. Request Submitted by (Forest Service use only)

1. Name

2. Region/Unit

3. Date

     

     

     

4. E-Mail

5. Phone Number

6. FAX Number

     

     

     

Section D. Explanation of Request (Forest Service use only)

 1. New Vendor

 2. Change to Vendor Information

 3. Assignment of Claim

 4. Volunteer (CCR Registration not required)



 5. Other. Please explain:      

Section E. EFT Exemption Certification

I certify that I am exempt from the requirement to receive payment by electronic funds transfer for the following reason:

 a) I do not have an account with a financial institution.

 b) Payment by electronic funds transfer would impose a hardship due to a physical or mental disability or a geographic, language, or literacy barrier, or would impose a financial hardship.








     

Signature



     

Date


The Vendor Code is used by the Forest Service accounting system to gather information about vendors, organizations or persons to whom money is owed or who owe money to the government.


31 USC 3325 requires Federal Agencies to include the Taxpayer Identification Number (TIN) of each payee on all payment vouchers. Treasury Financial Management Services’ Taxpayer Information Number Policy Directive provides limited exceptions.
31 USC 3332 requires Federal Agencies to issue payments by Electronic Funds Transfer (EFT); however, this requirement may be waived upon receipt of a written certification from the recipient that the recipient does not have a bank account or that payment by EFT would cause a hardship due to a physical or mental disability or a geographic, language, or literacy barrier, or would impose a financial hardship (31 CFR 208).
31 CFR Part 208 requires contractors to provide EFT information through the Central Contractor Registration (CCR) database.


Instructions


Section A – Vendor Information

  1. Provide the federal taxpayer identification number for business or partnership, social security number (SSN) for an individual, or individual taxpayer identification number (ITIN) for individuals who do not have, and are not eligible to obtain a Social Security Number (SSN).

  2. The Data Universal Numbering System (DUNS) number is a unique nine character identification number provided by the commercial company Dun & Bradstreet (D&B). The additional four digits (“+4”) are used to identify different CCR records for the same vendor at the same physical location. For example, a vendor could have two CCR records for themselves at the same physical location to identify two separate bank accounts. (http://www.ccr.gov).

  3. The VEND code is used by the Forest Service to define vendors, organizations, and persons to whom the Government makes payments or from whom the Government collects receivables. Provide the appropriate vendor code including alphabetic suffix, if known, for changes to an existing vendor code.

  4. Enter the name of the vendor or individual.

  5. Enter the vendor’s representative to be contacted, if necessary.

  6. Enter the vendor’s remittance address, or the provider’s billing address, as it should appear on checks or bills.

  7. Enter the vendor’s phone number

    1. Enter the vendor’s city, state, and zip code for the remittance address, or the provider’s billing address.

Section B – Banking Information for EFT

  1. Select the appropriate box to indicate whether or not EFT information is provided. If EFT information is not provided, check the applicable box

  2. Enter the Bank name of the account to be deposited to. For assignments enter the assignee’s bank name.

  3. Enter the city, state, and zip code for the bank identified. For assignments enter the assignee’s bank information.

  4. Enter the ABA routing number of the vendor’s bank. For assignments enter the assignee’s bank routing number to which EFT payments will be deposited.

  5. Enter the bank account number to which payments will be deposited. For assignments enter the assignee’s bank account number to which EFT payments will be deposited.

  6. Identify the type of account (Checking or Savings)

Section C - Request Submitted by

1-6 Identify the Forest Service personnel providing the information to be contacted, if necessary



Section D - Explanation of Request

1-6 Check the box that explains the reason for the request. If none of the boxes apply, check other and provide additional information in the blank box provided.

For assignments please attach a copy of the Assignment of Claim form.


  1. If none of the boxes apply provide an explanation in the blank box provided.

Section E - EFT Exemption Certification

If none of the exceptions listed in item B1 apply and EFT information is not provided, the individual or organization representative must certify exemption from EFT requirement by selecting the applicable box. (31 USC 3332) This exemption is not available to commercial vendors.




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