ihs form 856-6

ATTACHMENT IV
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
DELINQUENT FEDERAL DEBT
(Required form)
APPLICANT’S NAME

SOCIAL SECURITY NUMBER

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007
See Estimated Average Burden Time
per Response on Reverse Side.

CAREER CATEGORY

EMAIL ADDRESS

INDIAN HEALTH SERVICE OFFICE APPLYING THROUGH

INSTRUCTIONS:
The applicant must complete and forward this sheet with the application and required documents. Please
check the appropriate box below. If the “Yes” box is checked, please provide an explanation in the space
provided.
Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct student loans,
FHA loans, and other miscellaneous administrative debts. The definition of delinquency for the purposes of
direct and guaranteed loans are any loan(s) more than 31 days past due on a scheduled payment. Deferred
loans are not considered delinquent by the Indian Health Service.
ARE YOU DELINQUENT ON THE REPAYMENT OF ANY FEDERAL DEBT(S)
No
Yes
If your response was “Yes,” please provide an explanation in the space provided below. Explanation must
include name of Federal Agency (Debt), type (student loan, HUD Mortgage, etc.), telephone number and
name of contact person(s) handling debt, and account number if different from your SSN. You must also
provide a notarized power of attorney authorizing IHS Grants Management Branch personnel to inquire
on your debt. If authorization is not included, your application will not be considered for an award.

I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I understand
that it may be investigated and that any willfully false representation is sufficient cause for rejection of this application, or , if awarded
a Scholarship, that I am liable for repayment of all awarded funds and, further, that any false statement herein may be subject to
penalties under U.S. code, Title 18, Section 1001.
APPLICANT’S SIGNATURE

IHS-856-6
(Rev. 5/07)

DATE

EF

ATTACHMENT IV (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 8 minutes
per response including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it display a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Indian Health Service, OPHS/DHPS/Scholarships Branch, 801 Thompson Avenue, TMP Suite 450, Rockville,
MD 20852, ATTN: PRA (0917-0006).