VA Form 10-0491k, VA SCHOLARSHIP OFFER RESPONSE

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OMB Control No. 2900-0793
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/20XX

Health Professional Scholarship Program (HPSP), Visual Impairment and
Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

VA SCHOLARSHIP OFFER RESPONSE
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 U.S.C. §7501 (VIOMPSP), §7611 (HPSP) for VA
to determine your 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 your 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 your request for a scholarship. If you
give VA your social security number, VA will use it to obtain information relevant to determining whether to grant a scholarship, and to administer your scholarship, if
awarded. It also may be used for other purposes authorized or required by law.
VA BURDEN STATEMENT: 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. The OMB control number for this project is 2900-0793, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No.
2900-0793 in any correspondence. Do not send your completed VA Form 10-0491k to this email address.
1. APPLICANT INFORMATION (Last, First, MI)

2. SOCIAL SECURITY NUMBER (999-99-9999)

3. HOME ADDRESS (Address, State, Zip Code)

4. EMAIL ADDRESS

5. PHONE NUMBER: (Include Area Code) ((999) 999-9999)

6. SECONDARY EMAIL ADDRESS

7.

I acknowledge and understand that the VA will require me to maintain enrollment, acceptable level of academic standing and complete all coursework in the
program of study/degree program for which the scholarship was awarded for.
I acknowledge and understand that the VA will me to follow the scholarship program's policies and procedures to ensure I remain in good standing. Procedures
may include but not limited to notifying any changes to my enrollment status, plan of study, academic standing, contact information, bank information or other
situations that may have an impact with continuing the scholarship program.
I acknowledge and understand I am required to complete the obligated service at a VA facility in a full-time position after I have met all coursework/program of
study/degree requirements and VA qualification standards.
I acknowledge and understand that the VA agrees to provide an assignment, location, and appointment to a full-time position in the profession for which the
scholarship was awarded for.
I acknowledge and understand that I agreed to the mobility agreement in relocation at my own expense when the VA provides an assignment, location, or
appointment to complete my residency program or employment to a full-time position in the profession for which the scholarship was awarded for.
I acknowledge and understand that I am subject to the penalties described in the HPSP/VIOMPSP agreement if I fail to meet the conditions and terms of my
obligation to the VA in exchange for receiving the scholarship award.
I acknowledge and agree that all terms and conditions of the scholarship program have been explained to me.
Applicable for HPSP Scholarship Program only: I acknowledge and understand that I will make every effort to attend a required clinical rotation/tour in an
assignment or location with an affiliation agreement with a VA facility while enrolled in the course of education for which the scholarship was provided for.

ACCEPTANCE OR DECLINATION OF THE HPSP/VIOMPS SCHOLARSHIP AWARD
The scholarship award will not be issued until this form is complete and received. Please indicate whether you are accepting or declining the Department of Veteran
Affairs scholarship award by checking the appropriate box.
1.
2.

ACCEPT THE HPSP SCHOLARSHIP PROGRAM FOR THE 20

- 20

ACADEMIC YEAR.

DECLINE THE HPSP SCHOLARSHIP PROGRAM FOR THE 20

- 20

ACADEMIC YEAR.

ACCEPT THE VIOMPS SCHOLARSHIP PROGRAM FOR THE 20
DECLINE THE VIOMPS SCHOLARSHIP PROGRAM FOR THE 20

- 20
- 20

ACADEMIC YEAR.
ACADEMIC YEAR.

PAYMENT INFORMATION
The following information needs to be complete and accurate for direct deposit of stipends or other related costs to be issued. Please indicate which account type you
want for direct deposits and provide the financial institution, account number and routing number. NOTE: Direct deposits of funds are required.
1. NAME OF FINANCIAL INSTITUTION
2.

CHECKING ACCOUNT

3. ACCOUNT NUMBER

4. ROUTING NUMBER

SAVINGS ACCOUNT

CERTIFICATION AND ACKNOWLEDGMENT
I confirm all checked boxes reflect my understanding and agree with the information provided.
I acknowledge, confirm and certify that all information disclosed is accurate to the best of my knowledge.
NAME (Print)

VA FORM
XXX 20XX

10-0491k

SIGNATURE

DATE (MM/DD/YYYY)

106A4

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