Form 10-264 Academic Verification

OMB Control No. 2900-XXXX
Estimated Burden: 60 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

ACADEMIC VERIFICATION

1. Applicant must sign and date the "Consent for Release of Information."
2. This "Academic Verification" form is part of the application package and must be completed by the Dean/Program Director, or Administrative Chair of applicant's
program.
3. The applicant is responsible for ensuring that all documents are returned to the scholarship program office by the due date.
4. Submit completed documents as required by the application announcement or as a last option to:
Readjustment Counseling Service Scholarship Program (RCSSP)
Department of Veterans Affairs
Readjustment Counseling Service (10RCS)
810 Vermont Ave., NW • Washington, DC 20420

CONSENT FOR RELEASE OF INFORMATION
CONSENT: I authorize the educational institution in which I am, or will be, enrolled to release to VA information regarding my enrollment status and academic standing,
including grade point average, both now and while I am participating in the VA Readjustment Counseling Service Scholarship Program (RCSSP) as well as the plan of
study and projected costs. I understand that this authorization is voluntary, and that I may revoke this consent at any time. However, I further understand that if I
voluntarily revoke this authorization after the award of the scholarship, my scholarship award may be terminated and I may be liable for the damages in accordance with
provisions of 38 U.S.C. sections 17.545 -17.553.

Date Signed (MM/DD/YYYY)

Applicant's Signature

RCSSP

INFORMATION FROM APPLICANT

1. Name (Last, First, MI):

2. SSN:

3. Name of college or university where applicant is enrolled/accepted (Do Not Abbreviate):

4. Degree sought with this scholarship (Check one only):

Master's

5. Clinical Program (Check one only):

Social Work

Psychology

Doctorate
MHPC

MNFT

6. Please list the specific degree and specialty:

ACCREDITATION OF ACADEMIC PROGRAM
7. Name of the organization that accredited your academic program:

Accreditation expiration date (MM/DD/YYYY):

If program is not accredited, the applicant is not eligible for the scholarship program and this form does not need to be completed.
Representative from the program should explain the lack of accreditation to the applicant.
ADMISSION, ENROLLMENT AND PROGRAM COMPLETION INFORMATION
8. Applicant enrollment status (check one).

To be eligible for the scholarship award, the student must be
unconditionally admitted to the program and degree level by the
time the awards are granted. Therefore, it is critical that an
"Addendum to Application" form is submitted by the school if the
admission status changes.

Unconditionally admitted
Conditional/Pending admission (Please explain, including anticipated date

of meeting requirements for unconditional admission)

Probational admission (Please explain)

8a. Explanation:

9. What is full-time enrollment at your university/college?
10. Will the applicant be attending full-time or part-time? (RCSSP)
11. Date the applicant started or will start the program
under this scholarship program (MM/DD/YYYY):

Credit Hours per
Full-time

Semester

Quarter

Part-time
12. Date that classes begin for the upcoming
fall semester/quarter (MM/DD/YYYY):

13. Expected date that academic requirement(s), including all clinical rotations and/or projects will be completed (MM/DD/YYYY):
14. Expected date degree will be conferred (MM/DD/YYYY):
VA FORM
NOV 2021

10-264

10RCS

PAGE 1 OF 6

RCSSP ACADEMIC VERIFICATION (continued)
Applicant Name:

SSN:

CUMULATIVE GRADE POINT AVERAGE (CGPA)

For Graduate Students

Undergraduate Cumulative Grade Point Average (CGPA) need not be identified if the student has completed 15 or more graduate hours and is pursuing a graduate degree.
If the student has not achieved 15 hours of graduate credit, identify CGPA and credit hours for all undergraduate hours and if applicable, CGPA on credit hours for all
graduate academic courses completed. For institutions that do not use numerical grades, check the N/A box and indicate whether or not the student is in Good Standing
(according to standards set by the school).
For Undergraduate Students
CGPA must be computed on all post-secondary academic courses taken within past 10 years. It should not be computed only on academic courses accepted as satisfying
the requirements of the degree for which the applicant is requesting a scholarship.
If the applicant completed academic courses more than 10 years ago, CGPA should be computed on all courses used for admission to the program for which the scholarship
is being requested.
15.

Undergraduate CGPA

based on

credit hours

Semester

Quarter

N/A

16.

Graduate CGPA

based on

credit hours

Semester

Quarter

N/A

Is Student in Good Academic
Standing? Graduate Students Only

Yes

No

**If there is a change in the CGPA status after submission of this document, forward the ADDENDUM to the Scholarship Program immediately.

PLAN OF STUDY AND PROJECTED COSTS
17. For each term please
list:

• Course number and title
• Total credit hours for the term

• Credit hours for each course
• Projected tuition cost

(*Do not include books, supplies, equipment,
room/board, or meal plans)

Allowable Fees: • Required fees for approved curriculum such as laboratory expenses
• Malpractice insurance (if required for all students in the same

academic program)

• Matriculation fees
• Graduation fees
• Library fees

Note: See Invoicing Guidance for a consolidated list of Allowable Fees
Non-Allowable Fees: • Books
• Health/medical/dental/vision/life insurance
• Computers and software
• Study abroad fees
• Late charges

• Travel costs for clinical rotations
• Parking fees
• Membership dues for student societies, associations and similar expenses
• Licensure/Certification Courses/Reviews (Annual lump-sum "Other Related
Costs" payments may be used to pay for these items.)

Note: See Invoicing Guidance for a consolidated list of Non-Allowable Fees
Notes: • Tuition and fees will not be paid for courses that are being repeated.
• Specifically identify fees and whether required or optional.
SEMESTER/QUARTER
Course Number

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

VA FORM 10-264, NOV 2021

Total Projected Cost
for Semester

10RCS

PAGE 2 OF 6

RCSSP ACADEMIC VERIFICATION (continued)
Applicant Name:

SEMESTER/QUARTER
Course Number

SSN:

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

SEMESTER/QUARTER
Course Number

Start Date (MM/DD/YYYY):

Total Projected Cost
for Semester

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

VA FORM 10-264, NOV 2021

Total Projected Cost
for Semester

10RCS

PAGE 3 OF 6

RCSSP ACADEMIC VERIFICATION (continued)
Applicant Name:

SEMESTER/QUARTER
Course Number

SSN:

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

SEMESTER/QUARTER
Course Number

Start Date (MM/DD/YYYY):

Total Projected Cost
for Semester

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

VA FORM 10-264, NOV 2021

Total Projected Cost
for Semester

10RCS

PAGE 4 OF 6

RCSSP ACADEMIC VERIFICATION (continued)
Applicant Name:

SEMESTER/QUARTER
Course Number

SSN:

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

SEMESTER/QUARTER
Course Number

Start Date (MM/DD/YYYY):

Total Projected Cost
for Semester

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

VA FORM 10-264, NOV 2021

Total Projected Cost
for Semester

10RCS

PAGE 5 OF 6

RCSSP ACADEMIC VERIFICATION (continued)
Applicant Name:

SEMESTER/QUARTER
Course Number

SSN:

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

SEMESTER/QUARTER
Course Number

Start Date (MM/DD/YYYY):

Total Projected Cost
for Semester

End Date (MM/DD/YYYY):

Course Title

Credit Hrs

Tuition

Total CH

Total Tuition

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Cost

Total Fees

Total Projected Cost
for Semester

Please enclose a copy of the school's academic program curriculum.
THE PAPERWORK REDUCTION ACT OF 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore,
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 complete this form will average 60 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out
the form.
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 CFR, sections 17.545 through 17.553 (RCSSP) in
order for VA to determine the applicant's eligibility to receive a scholarship award. VA may disclose the information that you put on the form as permitted by law. VA may
make a "routine use" disclosure of the information for: civil or criminal law enforcement; congressional communications; the collection of money owed to the United
States; litigation in which the United States is a party or has interest; the administration of VA training and scholarship programs, including verification of the applicant's
eligibility to participate; and personnel administration. You do not have to provide this information to VA but, if you do not, VA may be unable to process the applicant's
request for a scholarship. If you give VA a social security number, VA will use it to obtain information relevant to determining whether to grant a scholarship, and to
administer the applicant's scholarship, if awarded. It also may be used for other purposes authorized or required by law.

CERTIFICATION
I understand it is my responsibility to notify the scholarship program if there are any changes in CGPA, admission status, enrollment status, plan of study, projected costs,
or program accreditation. I certify the accuracy of all information stated on this Form.

Name (Print)

Signature (Dean/Program Director/Administrative Chair of Program)

Title

Phone Number (include area code)

Date (MM/DD/YYYY)

E-mail Address

(Forward the ADDENDUM to the Scholarship Program immediately. Inaccurate data may cause both the school and the student to lose funding.)
VA FORM 10-264, NOV 2021

10RCS

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