10-264F Scholarship Agreement

OMB Control No. 2900-XXXX
Estimated Burden: 15 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP) AGREEMENT
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 15 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.

INSTRUCTIONS: Do Not Make Alterations to this Document. Only Use Ballpoint Pen to Complete.
SECTION A - The Readjustment Counseling Service Scholarship
5. Notify the Scholarship Program office in writing, of any of the following
Program (RCSSP) is described in 38 CFR sections 17.545 through 17.553.
changes within 10 days: change in name, address, telephone number,
enrollment status, plan of study, or academic standing.
SECTION B - Obligation of the Under Secretary for Health (USH).
1. Provide the undersigned participant with an RCSSP award
consisting of the payment of tuition, reasonable educational
expenses, and a monthly stipend, as authorized by 38 CFR section
17.547.

6. Submit required documentation periodically to the Scholarship Office at
times determined by VA in order to continue receiving the scholarship
award. Notify RCSSP program officials of changes in address, phone
numbers, and enrollment status.

2. Ensure that each participant selected for the RCSSP is an eligible
applicant, pursuing a degree in a qualifying field of education or
training designated by the USH for participation in the program.

7. Complete all coursework within the time frame indicated on the
application or any change in dates approved by the Scholarship Program.

3. Appoint the participant to a full-time position providing health
services in accordance with Section C13 of this agreement. This
employment will begin no later than 180 days after the participate
completes the RCSSP required education or training and meets all
the applicable qualification and licensure requirements for
appointment to the position. This time period may be extended at
the USH's discretion. At least 60 days prior to the appointment
date, the participant will be notified of location and beginning date
of obligated service.
4. Assign a mentor to the scholarship participant when it is determined
when and where the participant will be performing the obligated
service. The mentor will monitor participants to ensure State
licenses are obtained in a minimal amount of time following
graduation and the required period of supervision for their
profession.
SECTION C - Obligation of the Participant. In return for payments under
the RCSSP, the participant agrees to:
1. Accept the RCSSP award provided by the USH under Section B1 of
this agreement.
2. Pursue a degree in a qualifying field of education or training
designated by the USH for participation in the scholarship program
and the degree designated in the application for the scholarship
program.
3. Maintain enrollment as specified in the scholarship application until
completion of the course of study for which the scholarship award
is provided.

8. Ensure that the RCSSP program officials have access to educational or
training institution official transcripts, and other information and
documents required to assess the academic standing, status, and progress
of the scholarship recipient.
9. Sign a mobility agreement in which the participant agrees to relocate, if
necessary, at his or her own expense, to complete a clinical tour or
service obligation period in accordance with Sections C13 of this
agreement.
10. Serve a period of obligated service.
a. All scholarship participants in the RCSSP must serve a period of
obligated service as a full-time employee in the Veterans Health
Administration (VHA) in an assignment and location determined by
the USH.
b. This employment will begin within 180 days after the participant
completes the RCSSP-supported education or training and meets all
the applicable qualification requirements for appointment to the
position.
c. If the participant requests a deferment, an additional period of service
obligation may be required, at the discretion of the USH. No credit of
time for any advanced clinical training or residency will be counted
toward satisfying the obligated service period.
d. Each full-time student will incur a service obligation of 6 years
regardless of profession, psychology, social work, mental health
counseling, or marriage and family therapy, or terminal degree
obtained, masters or doctorate.

4. Maintain an acceptable level of academic standing, as determined
by the educational institution, while enrolled in the course of study
for which the scholarship award is provided.
Applicant's Name:
VA FORM
NOV 2021

10-264F

Applicant's Initials:
10RCS

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READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP) (continued)
SECTION D - Breach of RCSSP Agreement. If a participant, defined as an
applicant who has been selected for and accepted a scholarship award:

The amount the United States is entitled to recover may be offset against
any salary, wages, accrued leave or retirement annuity which the
participant is owed at the time the participant was terminated or failed to
1. Fails to accept payment or instructs the educational institution to which complete the required obligated service.
the scholarship payments are to be made not to accept payments under
this agreement, the participant (other than a participant under
SECTION E - Cancellation, Suspension, and Waiver of Obligation.
paragraph 2 of this section) shall, in addition to the service or other
1. Any service or payment obligation incurred under this agreement will
obligations incurred under this agreement, pay to the United States the
be canceled upon the death of the participant.
sum of $1,500 as liquidated damages. Payment of this amount must be
made within one year of the date on which the participant fails to
2. The USH may waive or suspend the participant's service or payment
accept payment of the HPSP award or instructs the school not to accept
obligation incurred under this agreement if:
payment.

2. Fails to maintain an acceptable level of academic standing in the course
of study for which the award is provided; is dismissed from the
educational institution for disciplinary reasons; voluntarily terminates,
for any reason, the course of study or program for which the award was
granted including a reduction of course load from full-time to part-time
before completing the course of study; fails to become licensed and/or
certified in the occupation for which the education and training was
provided within one year from the date such person becomes eligible to
apply for the licensure, or fails to meet any applicable licensure
requirement in the case of any other healthcare personnel who provide
either direct patient-care services or services incident to direct patientcare services, during a period of time determined under regulations
prescribed by the USH; or, fails to maintain employment, while
enrolled as a part-time student in the course of training being pursued
under the HPSP as a Department employee. In such cases the
participant shall, instead of performing the service obligation incurred
under this agreement, repay to the United States all funds paid to the
participant under this agreement. Payment of this amount must be
made within one year from the date of breach.

a. Compliance by the participant with the terms and conditions of the
agreement is impossible due to circumstances beyond the control of
the participant, or
b. In cases not related to paragraph 2.a. of this Section, when
considered in the best interest of the VA. Such decisions will be
made by the USH on an individual basis.
3. Requests for waiver of obligation must be submitted to the USH
within one year of the date the participant is determined, by the USH,
to be in breach of the agreement.
SECTION F - Consent for Release of Information.
The undersigned participant consents to allow the educational institution
to report status and academic standing including grade point average at the
time of application and, if selected, during the period of award
participation. The participant understands that this authorization is
voluntary and the participant may revoke the consent at any time.
However, the participant further understands that if this authorization is
voluntarily revoked after the award of the scholarship, the scholarship
award may be terminated and the participant may be liable for damages in
accordance with the provisions of 38 CFR section 17.553.

3. Breaches the agreement by failing for any reason to begin or complete
such participant's period of obligated service, or by failure to comply
with the terms and conditions of deferment. The United States shall be
SECTION G - General Provisions.
entitled to recover from the participant an amount of triple damages
determined in accordance with the following formula:
The Under Secretary for Health or authorized representative must accept
A=3P((t-s)/t) in which
this agreement before it becomes effective. The regulations and other
documents issued by the Under Secretary for Health to implement the
"A" is the amount the United States is entitled to recover.
RCSSP are incorporated into and made a part of this agreement.
"P" is the sum of:
a. The amounts paid under this agreement, to or on behalf of the
participant; and
b. The interest on such amounts which would be payable if at the
time the amounts were paid they were loans bearing interest at the
maximum legal prevailing rate, as determined by the Treasurer of
the United States.
"t" is the total number of months in the participant's period of obligated
service, including any additional period of obligated service in
accordance with 38 CFR sections 17.545 through 17.553.
"s" is the number of months of such period served by the participant in
accordance with 38 CFR sections 17.545 through 17.553. The amount
the United States is entitled to recover shall be paid within one year of
the date the USH determines that the participant has failed to begin or
complete the period of obligated service.

VA FORM 10-264F, NOV 2021

I understand the period of obligated service for this agreement is

I have read and understand the above agreement. I agree to comply
with the published statutes, regulations and policies governing the
Readjustment Counseling Service Scholarship Program and to be
subject to any changes in program policy.

Applicant's Name (Print)

Applicant's Signature

Date (MM/DD/YYYY)

Signature of Under Secretary for Health (USH)
or, Authorized Representative

Date (MM/DD/YYYY)

10RCS

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