Form IHS-856-5 Delinquent Federal Debt

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

See Estimated Average Burden Time
per Response on Reverse Side.

DELINQUENT FEDERAL DEBT
APPLICANT’S NAME

CAREER CATEGORY

SOCIAL SECURITY NUMBER

IHS AREA OFFICE

EMAIL ADDRESS

INSTRUCTIONS:
The applicant must complete and forward this sheet with their application and required supporting documentation.
Please check the appropriate box below. If the “Yes” box is checked, please provide an explanation in the
space provided.
Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct student loans, FHA
loans, and other miscellaneous administrative debts. The definition of delinquency for the purposes of direct and
guaranteed loans are any loan(s) more than 31 days past due on a scheduled payment. Deferred loans are not
considered delinquent by the Indian Health Service.
ARE YOU DELINQUENT ON THE REPAYMENT OF ANY FEDERAL DEBT(S)?
Yes
No
If your response was “Yes,” please provide an explanation in the space provided below. Explanation must include
name of Federal Agency (to which debt is owed), type (student loan, HUD Mortgage, etc.), telephone number and name
of contact person(s) handling debt, and account number if different from your SSN. You are required to provide
a notarized power of attorney, in some cases the Federal Agency may require you to use their power of
attorney document, authorizing the release of information to the IHS Division of Grants Operations to inquire
about your debt. If authorization is not included, your application will not be considered for an award.
Federal Agency

Type of Loan

Account #

Contact Name

Phone #

I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I understand that it may be investigated and that
any willfully false representation is sufficient cause for rejection of this application, or, if awarded a scholarship, that I am liable for repayment of all awarded funds and,
further, that any false statement herein may be subject to penalties under U.S. code, Title 18, Section 1001.
APPLICANT’S SIGNATURE

IHS-856-5

DATE

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 8 minutes per response including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: Indian Health Service, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.