FL 10-90 Request to submit Quotation

DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

This letter is submitted to secure an quote for the information listed on the attached. It does not
constitute a purchase order; nor is it to be considered as authority for delivery or work to be started.
This letter authorizes you to contact the veteran listed on the attached for additional information and/or
to schedule an appointment for evaluation. Based upon your assessment, you are required to provide
us the most accurate quote possible.
Your quote is expected within five (5) business days from the date of this letter unless you notify the
VA Approving Official.
Please fill out the attached and return via facsimile to the Department of Veterans Affairs facility
indicated above. Consideration of the purchase of the item(s) listed in the attached will be made and,
if approved, a purchase order will be prepared and forwarded to you. At that time, you are authorized
to start work.
You may retain one copy of this letter and the attached for your files.
If you have any questions, please contact the VA Approving Official at the telephone number listed on
the attached.
Sincerely,

Attachment: VA Form FL 10-90

VA FORM
SEP 2008

FL 10-90

OMB Number: 2900-0188
Estimated Burden: 5 minutes

REQUEST TO SUBMIT QUOTATION
PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be used to
determine the cost effective company. Additional information may be solicited during the course of processing your application. The information you supply may
also be disclosed outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register.
Disclosure is voluntary, however, failure to furnish the information will result in our inability to process your quotation promptly.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section
3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it
displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 5 minutes. This includes the
time it will take to read instructions, gather the necessary facts and fill out the form.
INSTRUCTIONS: Please fill out vendor estimate in Section II below and submit to the requesting VA facility.

SECTION I - (To be completed by requesting VA Facility)
VENDOR

REQUESTING VA FACILITY

Name:

Name:

Address:

Address:

Phone Number:

Phone Number:

Fax Number:

Fax Number:
VETERAN INFORMATION

Name:
Phone Number:

Your firm is being considered as a possible source for the following:

An estimate for the above listed items(s) is requested. YOUR QUOTATION DOES NOT CONSTITUTE A PURCHASE ORDER NOR IS IT TO BE
CONSIDERED AS AUTHORITY FOR DELIVERY OR WORK TO BE STARTED. This request authorizes you to contact the above named veteran for
additional information and/or to schedule an appointment for evaluation. Upon completion of the estimate, return via facsimile to the Department of Veterans
Affairs facility indicated above. Your estimated is expected within 5 business days from the date of the request unless you notify the VA Approving Official.
Consideration of the purchase of the above will be made, and, if approved, a purchase order will be prepared and forwarded to you. You may retain a copy of this
request for your files.

Name and Title of VA Approving Official

Date

SECTION II - VENDOR'S ESTIMATE (To be completed by Vendor)
Estimate should be itemized, separating materials from labor costs
HCPCS (if known)

Item(s) or Service(s)

Qty

Unit

Unit Cost

Sub Total
Less Discount (if applicable)
Total

Name and Title of Company Official
VA FORM
SEP 2008

FL 10-90

Date

Total Cost