10-264K Scholarship Offer Response

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

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

VA SCHOLARSHIP OFFER RESPONSE

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.

Applicant's Name (Last, First, Middle):
Please indicate whether you are accepting or
declining the Department of Veterans Affairs
scholarship award by checking the appropriate
space below.

Social Security Number:
Readjustment Counseling Service Scholarship Program (RCSSP)
I accept the scholarship award for the 20

- 20

school year.

I decline the scholarship award for the 20

- 20

school year.

The scholarship award will not be issued until this
form is completed and received by the scholarship
program office.
A. I understand that the VA will require me to maintain enrollment, an acceptable level of academic standing, and complete
all coursework in the course of study for which the scholarship award is provided.

Initial

B. I understand that the VA will require me to notify the scholarship program in writing, within 10 days if I change my
enrollment status, plan of study, academic standing, name, mailing address, telephone number, e-mail address, or bank
information.

Initial

C. I understand the required service obligation to work in a VA health care facility in a full-time position for which I will be
prepared after completing the education program supported by the scholarship program.
D. I understand that the VA agrees to provide an appointment to a full-time position providing health services in the
profession for which the scholarship is provided.
E. I understand that I may be subject to the penalties as described in the scholarship agreement if I do not complete the
education program for which I am requesting scholarship support or if I do not complete the required service obligation.
I accept this scholarship award with the terms and
conditions that have been explained to me, and
which are included in this document.

Initial
Initial

Date (MM/DD/YYYY)

Applicant's Signature

My address, e-mail, and phone number are the same as on my application.

Initial

Please update my contact information as indicated below.

New Address (Include Street Address, City, State, and ZIP Code):

New E-mail:

New Phone Number:

Payment Information for the direct deposit of stipends and reimbursement of other related costs. Direct deposit of funds is required.
Name of Financial Institution:
Please indicate Account Type:

Account Number:
Checking

Routing Number:

Savings

If you have any questions please contact the Department of Veterans Affairs, RCSSP Clinical Team at
[email protected]
Complete this form and return immediately to:
RCSSP
Department of Veterans Affairs
Readjustment Counseling Service (10RCS),
810 Vermont Ave., NW, Washington DC 20420
Retain this attachment until you are notified of your selection as a scholarship recipient.
Do not mail this form with your application.
VA FORM
NOV 2021

10-264K

10RCS

Page 1