10-264A Addendum to Application

OMB Control No. 2900-XXXX
Estimated Burden: 10 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

ADDENDUM TO APPLICATION

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 10 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.
If there are any changes in CGPA, admission status, enrollment status, plan of study, projected costs, or program accreditation,
immediately forward this ADDENDUM along with supporting documentation to:
RCSSP, Readjustment Counseling Service (10RCS)
Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420.
Name of Applicant (Last, First, MI):

SSN:

Name of college or university where applicant is enrolled/accepted (Do Not Abbreviate):
Reason for addendum:
Cumulative Grade Point Average change

Admission status change

Enrollment status change

Projected cost change

Plan of Study change

Other:

Program accreditation change

Comments/New Information:

CERTIFICATION OF ACCURACY
I certify the accuracy of all information stated on this Form.
(Inaccurate data may cause both the school and the student to lose funding.)

Name (Print)

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

Title

Phone Number (include area code)

Date (MM/DD/YYYY)

E-mail Address

If you have any questions, please contact the Department of Veterans Affairs, Readjustment Counseling Service Clinical Team at
[email protected].
VA FORM
NOV 2021

10-264A

10RCS

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