multiple forms Application Handbook

Application for Participation in the IHS Scholarship Program

Scholarship_Applicant_Handbook_OMB

Scholarship Application

OMB: 0917-0006

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INDIAN HEALTH SERVICE

Application Handbook
Your Health Career Starts Here

Dear Scholarship Applicant:
Thank you for your interest in the Indian Health Service Scholarship Program.
You have already taken the first steps toward your future by furthering your
education, envisioning your career and setting goals. It’s just the beginning.
The IHS Scholarship Program can help you move closer to realizing the future
you envision for yourself.
The first IHS scholarship was awarded in 1977. Since then, millions of dollars
have been awarded to American Indian and Alaska Native students to help
them reach their career goals and dreams, while helping IHS to fulfill its
mission: to raise the physical, mental, social and spiritual health of American
Indians and Alaska Natives to the highest level. You can help with that
mission by traveling a path that brings you opportunity, adventure and a
sense of personal fulfillment, working in an Indian community where you’re
really needed — perhaps your own community.
This booklet contains information on the IHS Scholarship Program,
application forms, a step-by-step explanation for completing the application,
and a convenient checklist to assist you with the application. Please write
or call the program if you have any questions about the scholarships or the
application process.
On behalf of the Indian Health Service, we greatly appreciate your interest in
serving your fellow American Indian and Alaska Native people.

[Robert’s signature]
Robert E. Pittman, R.Ph., M.P.H.
Rear Admiral, USPHS
Assistant Surgeon General
Director, Division of Health Professions Support

Discrimination Prohibited
Title VI of the Civil Rights Act of 1964 states: “No person
in the United States shall, on the ground of race, color, or
national origin, be excluded from participation in, be denied
the benefits of, or be subjected to discrimination, under any
program or activity receiving federal financial assistance.”
Title IX of the Education Amendments of 1972 and its
implementing regulations (45 Code of Federal Regulations,
part 86) provide that no person in the United States shall, on
the basis of sex, be denied the benefits of, or be subjected
to discrimination under any education program or activity
receiving federal financial assistance.
Section 504 of the Rehabilitation Act of 1973, as amended,
provides that no otherwise qualified handicapped individual
in the United States shall, solely by reason of his handicap, be
excluded from participation in, be denied the benefits of, or
be subjected to discrimination under any program or activity
receiving federal financial assistance.

Privacy Act Notice
General
This information is provided pursuant to the Privacy Act of
1974 (Public Law 93-579), December 31, 1974, for individuals
supplying information for inclusion in a system of records.

Authority
Sections 751-757 of the Public Health Service Act and Sections
102 and 104 of the Indian Health Care Improvement Act
(IHCIA) (P.L. 94-437), as amended by the Indian Health Care
Amendments of 1988, 1992, and 1996 (P.L. 100-713, P.L.
102-573 and P.L. 704-313).

Purposes and Uses
The purpose of the Indian Health Service Scholarship Program
is to obtain health professionals to meet the staffing needs of
Indian health programs in health manpower shortage areas.

The information you supply will be used to evaluate your
qualifications and suitability for participation in the IHS
Scholarship Program. Selections are made on a competitive
basis. A recipient’s application and related data are made part
of the file to be used within the Department of Health and
Human Services for record-keeping and participant management while the recipient is in the program. The information
may also be disclosed outside the Department as permitted
by the Privacy Act, including disclosures to the public as
required by the Freedom of Information Act, to the Congress,
the National Archives, the Bureau of Accounting Office, and
pursuant to court order. The name of a scholarship recipient,
the professional school he or she is attending, and the date
of graduation, may be made available to health professions
associations and to groups who have responsibility for coordinating funds paid to students from federal and other sources,
and to individuals and organizations deemed qualified by the
Secretary to carry out specific research solely for the purpose
of carrying out such research. You are asked to provide your
Social Security number on a voluntary basis. Should you not
provide this information and you are awarded a scholarship,
you will be required to provide it later for purposes of payroll
and payments of scholarship benefits to you.

Effects of Non-Disclosure
Disclosure of the information sought is voluntary; however,
if not submitted, except for the Social Security number, an
application will be considered incomplete and chances for
selection will be diminished.

Application Deadline
The application deadline is March 28. All application
materials must be postmarked by the IHS Scholarship
Program office by this date. Meeting the deadline is your
responsibility. No extensions will be granted. It is to your
advantage to submit with your application all the forms
and documents that may be required.

An Important Reminder
IHS Scholarship opportunities are highly competitive and there
are no guarantees that you will receive an award. If you are
applying for any of the IHS scholarships, you should continue
your efforts to obtain financial aid from other sources as well.

TABLE OF CONTENTS
The IHS Scholarship Programs

Preparatory Scholarship Program

IHCIA (Public Law 94-437) Section 103(b)(1)

Pre-Graduate Scholarship Program

IHCIA (Public Law 94-437) Section 103(b)(2)

Health Professions Scholarship Program

IHCIA (Public Law 94-437) Section 104
Preparatory Scholarship Program Details

Priority Health Career Categories

Specific Requirements for the Preparatory Scholarship

Support

Continuation Eligibility

Pre-Graduate Scholarship Program Details

Priority Health Career Categories

Specific Requirements for the Pre-Graduate Scholarship

Support

Continuation Eligibility

Health Professions Scholarship Program Details

Priority Health Career Categories

Specific Requirements for the Health Professions Scholarship

Support

Continuation Eligibility

Scholarship Program Contract

Service Obligation

Employment Options

Deferments

General Eligibility Requirements for All Applicants

Citizenship

Documentation of American Indian/Alaska Native Eligibility

Complete and Eligible Application

How Participants Are Selected

Ranking Procedures

Selection Priorities

TABLE OF CONTENTS Continued
Program Benefits

Stipend for Student Living Expenses

Payment of Tuition and Required Fees

Items Paid

Items Not Paid

Payment for Other Reasonable Education Expenses

Your Scholarship Benefits are Taxable

Continuing Support After the Current Funding Period

Acceptance of Other Federal Benefits

Other Public Health Service Benefits

Veterans Benefits

Benefits From State, Local and Other Federal Sources

How to Apply

Application Deadline

Important Reminders

Step-by-Step Instructions

Application Checklist Form

Instructions for the Application Form IHS-856

Instructions for Letter of Acceptance

Instructions for Official Transcripts

Instructions for Eligibility Documentation

Faculty/Employer Evaluations Form

Reasons for Requesting Scholarship Form

Delinquent Federal Debt Form

W-4 Form

Verification of Course Curriculum Form

Acknowledgement Card

Instructions for Curriculum for Major

Health Related Experience (MPH Only)

The IHS Scholarship Programs
Application Handbook

eer Starts Here
Scholarships

Health Professions
Preparatory
IHCIA Section 103 (b) (1)
Undergraduate Only

Health Professions
Pre-Graduate
IHCIA Section 103 (b) (2)
Undergraduate Only

Health Professions
IHCIA Section 104
Undergraduate &
Graduate Level

The IHS Scholarship Programs
American Indian and
Alaska Native Eligibility

Disciplines
• Pre-Nursing — Courses leading to a BS in nursing
• Pre-Medical Technology — Courses leading to a BS in medical technology
• Pre-Pharmacy — Courses leading to a PharmD degree in pharmacy
• Pre-Dietetics — Courses leading to a BS degree in dietetics
• Pre-Social Work — Juniors and seniors preparing for a Master of Science (MS)
in social work
• Pre-Physical Therapy — Juniors and seniors preparing for an MS degree
in physical therapy
• Pre-Engineering — Courses leading to a BS degree in engineering
• Pre-Sanitarian (Environmental Health)
• Pre-Occupational Therapy
• Pre-Clinical Psychology — Junior and senior undergraduate years
NOTE: Please visit www.scholarship.ihs.gov to see this year’s priority categories.
• Pre-Dentistry
• Pre-Medicine
• Pre-Podiatry
NOTE: Please visit www.scholarship.ihs.gov to see this year’s priority categories.
• Chemical Dependency Counseling — Bachelor’s and master’s degrees
• Clinical Psychology — PhD program
• Coding Specialist — Certificate
• Dentistry — DDS or DMD degree
• Dental Hygienist — BS degree
• Diagnostic Radiology — Technology certificate, associate’s degree and BS
• Dietician — BS degree
• Environmental Health and Engineering — BS degree
• Health Care Administration — BS and master’s degrees
• Health Education — BS and master’s degrees
• Health Records Administration — Registered Health Information Technician (RHIT)
and Registered Health Information Administrator (RHIA )
• Injury Prevention Specialist — Certificate
• Medical Technology — BS degree
• Medicine — Allopathic and osteopathic doctor degrees
• Nurse — Degrees: Associate Degree in Nursing (ADN), Bachelor of Science
in Nursing (BSN) Specialties: Certified Registered Nurse Anesthetist (CRNA),
GER, Nurse Practitioner (NP), PED, PSY, WH
• Occupational Therapy — BS degree
• Optometry — OD degree
• Pharmacy — PharmD degree
• Physician Assistant — Certified Physician Assistant (PAC)
• Physical Therapy — MS and Doctor of Physical Therapy (DPT) degree
• Physical Therapy Assistant — Associate degree
• Podiatry — DPM
• Public Health — Master of Public Health (MPH) with concentration
in epidemiology only
• Public Health Nutrition — Master’s degree
• Respiratory Therapist — Associate’s degree
• Social Work — Master’s degree with concentration in mental health
• Ultrasonagraphy — BS/Certification with completion of prerequisite
Diagnostic Radiology Technology
NOTE: Please visit www.scholarship.ihs.gov to see this year’s priority categories.

In September of 1976, the Congress and the President of the
United States enacted the Indian Health Care Improvement Act
(Public Law 94-437), which declared that “it is the policy of
this Nation, in fulfillment of its special responsibilities and legal
obligation to the American Indian people, to meet the national
goal of providing the highest possible health status to Indians
and to provide existing Indian health services with all resources
necessary to effect that policy.”

Service
Obligation

Years of
Funding

Descendents and
members of federally
or state recognized
Tribes are eligible.

None

Descendents and
members of federally
or state recognized
Tribes are eligible.

None

Members of
federally recognized
Tribes are eligible.

1 year of service
per year of support
for scholarship
received (minimum
of two years)

An Important Reminder
IHS Scholarship opportunities are highly
competitive and there are no guarantees
that you will receive an award. If you’re
applying for any of the IHS scholarships,
continue your efforts to obtain financial aid
from other sources as well.

To help accomplish this goal, the Act and subsequent amendments of 1980, 1988, 1992 and 1996 authorize the Indian
Health Service (IHS) to conduct three interrelated scholarship
programs, for American Indian and Alaska Native students,
to train the health professionals necessary to staff IHS health
programs and other health programs serving the Indian people.
You must submit documentation of American Indian/Alaska
Native eligibility when you apply. Please see page 14 for
further details.

Preparatory Scholarship Program

Pre-Graduate Scholarship Program

The Preparatory Scholarship Program provides financial assistance for American Indian and Alaska Native (federally or
state-recognized) students only to enroll in compensatory or
preparatory courses in preparation for entry to health professional schools, such as medical, nursing, pharmacy and others
as needed. Compensatory courses are those required to improve
science, mathematics or other basic skills and knowledge.
Preparatory courses are pre-professional studies required in
order to qualify for admission to a health professions program.

The Pre-Graduate Scholarship Program provides financial
support for American Indian and Alaska Native (federally or
state-recognized) students only to enroll in courses leading to
a bachelor degree in specific pre-professional areas, such as
pre-medicine, pre-dentistry and others as needed by Indian
health programs.

Health Professions Scholarship
Program
The Health Professions Scholarship Program is for American
Indian and Alaska Native (federally recognized only) students
enrolled in health professions and allied health professions
programs. Students incur service obligations and payback
requirements on acceptance of funding from this program.
Priority is given to graduate students and junior- and seniorlevel students unless otherwise specified.

Preparatory Scholarship Program Details
Priority Health Career Categories
To be considered for Preparatory Scholarship support during
this scholarship cycle, you must be accepted by or enrolled in
a college or university beginning in the fall term of this year
in a priority career category. Health career categories given
priority for scholarship awards change yearly, depending
on Indian health program staffing needs. Please visit
www.scholarship.ihs.gov to view this year’s priority list.

Specific Requirements for
the Preparatory Scholarship
Opportunities are available for American Indian and Alaska
Native (federally or state-recognized) students. Applicants must
meet the following requirements:
» High school graduate, or equivalent
» Capable of completing a health professions course of study
» Enrolled or accepted for enrollment in a compensatory/
pre-professional general education course or curriculum
» Intend to serve Indian people as a health care provider in
your chosen discipline or specialty
» Provide a course curriculum outline, advisor-signed and
approved, covering your major from first year to completion
(at least 12 credit hours per semester/quarter for full-time,
or six to 11 credit hours for part-time) and verifying that the
courses are preparatory to enrollment in your chosen health
professional program or are required to meet any educational deficiency and compensatory needs at the pre-professional level.

Support
Scholarship support is paid for ten months each academic year,
and is available for up to two academic years full-time or four
academic years part-time. Support covers costs of compensatory and pre-professional education that enables the student to
qualify for enrollment or reenrollment in a health professions
school (i.e., freshman and sophomore years of study leading
to a bachelor’s degree in a priority health profession, or the
last two years of undergraduate study required for entry into
graduate professional school). To receive priority consideration

for additional periods of scholarship support, students must
meet the continued eligibility requirements and be recommended for continuation by their IHS discipline chief.

Continuation Eligibility
To remain eligible for continued Preparatory Scholarship
funding, students must apply annually and meet the following
continued eligibility criteria:
» Be in good academic standing in their program
» Be enrolled for the next semester/quarter in at least 12
credit hours or the equivalent (full-time), or six to 11 credit
hours (part-time)
» Remain full-time or part-time during the current
academic year

Pre-Graduate Scholarship Program Details
Priority Health Career Categories

Support

To be considered for Pre-Graduate Scholarship support during
this scholarship cycle, you must be accepted by or enrolled
in a college or university beginning in the fall term of this
year in a bachelor degree program leading to entry into an
accredited professional school in a priority career category. IHS
Pre-Graduate Scholarships are awarded based on the health
professional staffing needs of Indian health programs. Categories may change from year to year, but typical priorities can
include pre-medicine, pre-dentistry and pre-podiatry. Priority is
given to undergraduate juniors and seniors, while freshmen and
sophomores will receive awards if remaining funds are available. Please visit www.scholarship.ihs.gov to view this year’s
priority list.

Pre-Graduate scholarship support is paid for ten months each
academic year, for up to four academic years full-time or eight
academic years part-time, for studies leading to enrollment
in an accredited professional school. Only those students who
meet the continuation eligibility criteria will be given priority
consideration for additional periods of support.

Specific Requirements for
the Pre-Graduate Scholarship
Opportunities are available for American Indian and Alaska
Native (federally or state-recognized) students. Applicants must
meet the following requirements:
» High school graduate, or equivalent
» Capable of completing a health professions course of study
» Enrolled or accepted for enrollment in a pre-professional
bachelor degree program, or equivalent
» Intend to serve American Indian and Alaska Native people as
a health care provider in your chosen discipline or specialty
» Provide a course curriculum outline, signed by a school official (preferably your advisor), covering your major from first
year to completion (at least 12 credit hours per semester/
quarter for full-time, or six to 11 credit hours for part-time)
and verifying that the coursework being taken is required for
an undergraduate curriculum leading to a bachelor’s degree
in a pre-professional program that will prepare you for
acceptance into a school of medicine or dentistry upon
its completion.

Continuation Eligibility
To remain eligible for continued Pre-Graduate Scholarship
funding, students must apply annually and meet the following
continued eligibility criteria:
» Be in good academic standing in their pre-graduate program
» Be enrolled for the next semester/quarter in at least 12
credit hours or the equivalent (full-time), or six to 11 credit
hours (part-time)
» Remain full-time or part-time during the current
academic year

Health Professions Scholarship Program Details
Priority Health Career Categories

Support

To be considered for Health Professions Scholarship support
during this scholarship cycle, you must be accepted by or
enrolled in a college or university professional school beginning in the fall term of this year in a priority career category.
Health career categories given priority for scholarship awards
changes yearly, depending on Indian health program staffing
needs. Please visit www.scholarship.ihs.gov to view this year’s
priority list.

Health Professions Scholarships are awarded for a one-year
period (12 months of support), with re-application required for
each year of continuation. Stipends are paid for the 12-month
period beginning each year from August 1 through July 31 for
health and allied health professional education up to four years
(full-time) or up to eight years (part-time). To receive priority
consideration for each year of scholarship support, students
must meet the continuation eligibility requirements and be
recommended for continuation.

Specific Requirements for
the Health Professions Scholarship
Opportunities are available for American Indian and Alaska
Native (federally recognized only) students. Applicants must
meet the following requirements:

Continuation Eligibility
To remain eligible for continued Health Professions Scholarship
funding, students must apply annually and meet the following
continued eligibility criteria:

» High school graduate, or equivalent

» Maintain an overall 2.0 grade point average in their chosen
health/allied health professions curriculum

» Enrolled or accepted for enrollment in a full- or part-time
study program in a priority category leading to a degree
from a health-related professions school within the US

» Be enrolled for the next semester/quarter in at least 12
credit hours or the equivalent (full-time), or six to 11 credit
hours (part-time)

» Sign a contract to practice at an Indian health program
priority site — one year of service for each year of scholarship support

» Submit a letter from the program director verifying the fulltime or part-time status of that institution’s health and allied
health program

» If a part-time student, submit documentation showing that
school and course curriculum allows part-time status

Scholarship Program Contract

» Will receive degree in no more than four years from time
of application
» Submit course curriculum for your major from first year
to completion

(For Health Professions Applicants Only)
A signed Indian Health Service Scholarship Program Contract
(Form IHS-818) must be submitted with your application. By
signing, you are agreeing to acceptance of funds (if you’re
selected) and to perform a service obligation with IHS after
graduation of one year for each year of scholarship support
received (or the part-time equivalent), with a two-year
minimum service period. To fully understand this obligation,
please read the contract carefully before signing and submitting.
Your obligations are defined in the contract’s Section B —
Obligations of the Applicant.
You may be liable for breach of contract if you fail to maintain
an acceptable level of academic standing in course studies, or
fail to begin or complete obligated service under the contract.
See IHS Scholarship Program Contract: Section C — Breach of
Scholarship Contract.

Health Professions Scholarship Program Details Continued
Service Obligation

Employment Options

Health Professions Scholarship Program recipients incur a
service obligation of 1 year for each year of scholarship support
received (or the part-time equivalent) with a minimum service
period of 2 years. After graduation, your active duty service
obligation is fulfilled, as designated by the Director of IHS, in
one of the following areas:

Before the service obligation begins, Health Professions
Scholarship participants will be given information on the two
personnel systems used by IHS: the US Public Health Service
(USPHS) Commissioned Corps and the Federal Civil Service. For
Tribal hire information regarding Indian Self-Determination Act
(P.L. 93-638) programs or Title V Urban programs, you may
contact those programs directly. The Indian Health Service Scholarship Program staff is also available for placement assistance.

» Indian Health Service (IHS)
» A Tribal health program (contracted under the Indian
Self-Determination Act [P.L. 93-638])
» An Urban Indian health program (assisted under Title V —
Health Services for Urban Indians, of the Indian Health Care
» Improvement Act [P.L. 94-437]) ,or
» Private practice in a designated health professional shortage
area addressing the health care needs of 51 percent of
Indians in that area.
You can also elect to fulfill the service obligation in one of the
above areas that is located on the reservation of the tribe or
serves the tribe in which the recipient is enrolled.
Assignment opportunities are reviewed with students and
approved early in the final school year. The Director of IHS
reserves the right to make final decisions regarding assignment
of scholarship recipients to fulfill their service obligation.
Although the ultimate responsibility for seeking a position
is the Health Professions Scholarship recipient’s, the IHS
Scholarship Program staff and IHS Discipline Representatives
are available to assist with and facilitate placement. Please
visit www.careers.ihs.gov for more information.
According to the Indian Health Care Improvement Act and
the Public Health Service Act, the active duty service obligation must be served in full-time (40 hours per week) clinical
practice. You will have an opportunity to find placement to
serve your active duty service obligation, consistent with the
statutory mandates listed above. However, if there is a difficulty
in placement, you may be assigned to an IHS geographic area
where there is an existing need.

Deferments
Post-Graduate Training
Health Professions Scholarship recipients may request deferment of their service obligation for further training. Detailed
information on this procedure is given in the spring of your
senior year and is outlined below. As an IHS scholarship obligated graduate, it is your responsibility to familiarize yourself
and comply with the information bulletin and instruction you
will receive. Failure to do so may result in non-approval of your
deferment request.
Deferment of the service obligation is intended to permit
scholarship recipients to complete approved graduate clinical
training programs (i.e., those programs of graduate clinical
training which fulfill the requirements for board certification and
have been approved by the appropriate certifying boards, as
determined by the Secretary, Department of Health and Human
Services). Training which fulfills the requirements for board
certification is considered by the IHS Scholarship Branch to be
the graduate clinical training and years of practice required by
the appropriate American specialty board for the candidate to
be board certified.

To be eligible to serve with IHS as an allopathic or osteopathic
physician, graduates must complete at least one year in an
approved graduate clinical training program. Completion of
post-graduate training is a critical factor in identification of the
practice in which the scholarship obligation is to be fulfilled.
Scholarship recipients who elect to serve after only one year of
graduate clinical training will compete with board eligible practitioners for a limited number of vacancies and may experience
difficulty in identifying assignments in which to serve. Therefore, in order to become fully qualified practitioners, graduates
are encouraged to complete training in an approved specialty.

» To be eligible to serve with the IHS as a licensed social
worker, and before they can sit for licensure boards, graduates must complete two years of clinical experience under a
licensed practitioner. This requirement may vary based upon
geographic location.
» To be eligible to serve with the IHS as a licensed clinical
psychologist, and before they can sit for licensure boards,
graduates must complete two years of clinical experience
under a licensed practitioner. This requirement may vary
based upon geographic location.
» To serve with IHS as a registered pharmacist, graduates may
elect to complete one additional year of training in an ASHP
accredited pharmacy residency program.

Note: No period of internship, residency or other advanced
clinical training shall be counted as satisfying any period of
obligated service that is required under Section 104 (b)(3)(A)
of the IHCIA, P.L. 94-437, as amended.

General Eligibility Requirements for All Applicants

The following are general eligibility requirements for students
applying for any one of the three IHS scholarship programs.
Applicants must meet both the general requirements and
the specific requirements listed for the individual scholarship
program they are applying for in order to be considered. The
detailed description for each separate scholarship program lists
the specific requirements for that program.

Citizenship
You must be a citizen of the United States at the time you apply
for an IHS scholarship award. Permanent resident aliens and
other aliens are not eligible to apply.

Documentation of American
Indian/Alaska Native Eligibility
Submit a copy of an approved Bureau of Indian Affairs (BIA)
Certification Form 4432 with your application. You must use BIA
Certification: Form 4432, as follows:
» American Indian: Category A — Members of Federally
Recognized Tribes, Bands or Communities
» Alaska Native: Category D — Alaska Native
In the absence of BIA certification, provide documentation that
you meet requirements of tribal membership as prescribed by
the charter, articles of incorporation or other legal instrument
of the tribe and have been officially designated as a tribal
member as evidenced by an accompanying document signed
by an authorized tribal official, or other evidence of tribal
membership satisfactory to the Secretary of the Interior.

If you are a member of a tribe terminated since 1940 or a
state-recognized tribe, provide official documentation that you
meet the requirements of tribal membership as prescribed by
the charter, articles of incorporation or other legal instrument
of the tribe and have been officially designated as a tribal
member as evidenced by an accompanying document signed
by an authorized tribal official; or other evidence, satisfactory
to the Secretary of Interior, that you are a member of the tribe.
In addition, if the terminated or State recognized tribe of which
you are a member is not on a list of such tribes published
by the Secretary of Interior in the Federal Register, you must
submit an official signed document that the tribe has been
terminated since 1940 or is recognized by the state in which
the tribe is located in accordance with the law of that state.
If you are not a tribal member but are a natural child or
grandchild of a tribal member, you must submit: (1) evidence
of that fact, i.e., your birth certificate and/or your parent’s birth
certificate showing the name of the tribal member; and (2)
evidence of your parent’s or grandparent’s tribal membership in
accordance with the paragraphs above. The relationship to the
tribal member must be clearly documented.
NOTE: If you meet the criteria of a terminated tribe or are
a descendent, you are only eligible for the Preparatory or
Pre-graduate Scholarships.

Complete and Eligible Application
Eligible applicants must submit complete their applications
by the deadline date to be considered for any IHS scholarship
award. Please see the How to Apply section on page 19 for
further instructions on completing your application.

How Participants Are Selected

IHS Scholarship Program awards are made on a competitive
basis to eligible students who meet certain selection criteria.
During the selection process, students are ranked with their
peers — juniors with juniors and seniors with seniors, for
example — for each priority health career category. The amount
of funds available each year determines the number of students
in each class year’s list that are selected for awards.
Applications from students in each of the health profession
priorities are reviewed and rated using the following three
criteria. Points totaling 100 are assigned as indicated for
each criteria.
Academic Performance (40 pts.)
Applicants are partially rated according to their academic performance, based on official transcripts and faculty evaluations. If
it is your school’s policy to not to rank students academically,
faculty members are asked to provide a personal judgment of
your achievement.
Health Profession Scholarship Program applicants only: You
must have a cumulative GPA of 2.0. If your GPA is below this
minimum standard, your application will not be reviewed.
Faculty, Employer and Tribal Recommendations (30 pts.)
Applicants are partially rated according to faculty, employer and
Tribal recommendations regarding the applicant’s potential in
their chosen health-related profession.
Stated Reasons for Asking for the Scholarship and
Stated Career Goals (30 pts.)
You are asked to explain why you are requesting the scholarship, to state your career goals, and to explain how these
goals will help to meet the health needs of American Indian
and Alaska Native people. You must provide a brief written
explanation of your reasons for asking for the scholarship and
a description of your career goals. The narratives weigh heavily
toward your rating and are judged by the review committee on
how well they are written.

Ranking Procedures
Eligible applicants with complete applications within each
career category are reviewed and rated as described above.
The scores are determined for each application and a rank order
listing is developed for each priority health career category,
beginning with the highest- and ending with the lowest-rated
application. A cut-off score is determined based on the health
professional needs of the Indian health programs, and on the
amount of funding available.

Selection Priorities
Priority consideration for funding will be given to:
» Applicants who provide documentation of American Indian/
Alaska Native eligibility (See page 14)
» Students currently enrolled in a health profession program
who are performing satisfactorily (2.0 GPA average) and
require continued scholarship support
» Current recipients of the Health Professions Preparatory
Scholarship Program or the Health Professions Pre-Graduate
Scholarship who have completed their coursework under
these programs, are entering a health professions school
and are applying in the priority health career categories
(See page 11)
» New applicants who are highly rated and ranked competitively according to the selection criteria (See page 33)
» Participants entering their fourth and third year of school, in
that order. Applicants entering their first or second year will
be considered only if an insufficient number of fourth- and
third-year students qualify.

Needs of Indian Health Programs and How the Applicant’s
Career Goals Relate to Those Needs — Individuals who apply
for health career categories not listed as priorities during the
scholarship cycle under review will not be considered.

Program Benefits

The level of IHS Scholarship Program benefits is dependent
on the availability of funds appropriated each fiscal year by
the Congress of the United States and, therefore, is subject
to change each year.

Health Professions Scholarship recipients will receive a stipend
for the 12-month period beginning August 1 through July 31.
The first stipend checks will be electronically transmitted via
direct deposit to their bank accounts from the Treasury Department at the end of the month of August.

Stipend for Student Living Expenses

Health Preparatory and Health Professions Pre-Graduate Scholarship recipients will receive a stipend for only the academic
period covered by their awards: August 1 to May 31. The first
stipend checks will be electronically transmitted via direct
deposit to their bank accounts from the Treasury Department
at the end of the month of August. Stipends for the months
of June and July will be paid only to those students who have
requested to attend summer sessions and have been approved
in advance to do so.

The estimated stipend amount for student living expenses,
including room and board, will be no less than $1,250 and
will be deposited at the end of each month. This amount is
pro-rated for part-time students. Each scholarship recipient will
receive an award letter specifying the total dollar amount for
the award.

Payment of Tuition and
Required Fees
IHS makes direct payment to the scholarship recipient’s school
for tuition and required fees for the school year. Summer
school is excluded unless specifically requested and approved
in advance. IHS will officially notify the school of the scholar’s
participation in the IHS Scholarship Program. Until the school
receives billing instructions, this notification of award authorizes
the school to bill IHS directly for tuition and required fees during
the first week of October.
IHS pays for tuition and fees directly applicable to the student’s
approved curriculum and program. Payment will not be made
for tuition and fees unrelated to the approved program, for
membership dues for student societies, associations and
similar expenses, or for school terms prior to the scholarship
award period.

Items Paid
IHS will pay for the following items:
» Tuition costs and mandatory fees. Any mandatory fees, such
as lab fees and health unit fees, are paid if they’re included
on the school’s invoice. The school should submit all invoices
to the Division of Grants Operations.
» Books, laboratory expenses and other education expenses.
These are paid in advance in a lump sum to the student for
the school year.
» Travel expenses of set amount $300 for the school year, paid
in advance to the student.
» Tutorial costs. A maximum of $400 for full-time or
$200 for part-time the academic year is paid directly
to the student, who must specifically request tutorial
services. Payment is subject to approval of the Scholarship
Branch Chief.

Items Not Paid
IHS will not pay the following items:
» School bookstore invoices or books/dental/medical equipment (unless certain dental/medical equipment is rented
from the school).
» Health insurance. Colleges/universities will accept documentation from your Tribe or Indian Health Service facility that
you are eligible for health care and/or contract health care
from through our Indian health programs. If you find that the
availability of health care services is inconvenient, you will
be responsible for a separate health insurance policy, group
or individual, while in school.

Payment for Other Reasonable
Education Expenses
Scholarship recipients receive a lump sum amount in their
August stipend check that is intended to cover the costs of
books, travel and other necessary education expenses. No
additional payments for such expenses will be made beyond the
lump sum amount. Certain expenses, such as daily commuting
and parking costs, are not covered by these payments.

Your Scholarship Benefits
Are Taxable
Scholarship funds are subject to federal income tax, and
possibly state and local taxes.
IHS withholds federal income taxes only from your stipend
checks. Please inquire in your state about any state tax liability
on your award. For instructions concerning allowances, exemptions and filing status, refer to the W-4 form for the current
year (see page 53) and/or contact your local Internal Revenue
Service office.

Continuing Support After the
Current Funding Period
IHS scholarships are awarded for one school year only, but
you can request continuing support annually if you fulfill the
criteria specified for your specific scholarship program (see
the detailed description for each program’s criteria). However,
continued funding depends on Congressional appropriation for
the program.

» Additional travel expenses incurred over the lump sum
amount of $300.

Acceptance of Other Federal Benefits
If you are currently receiving scholarship funding from other
federal agency sources, you should inform the awarding agency
if you are selected to receive an IHS scholarship. This is done to
eliminate duplicate payment of tuition and other educational
expenses. Additionally, the awarding agency might prohibit
duplicate awards.

Other Public Health Service Benefits
If you are receiving scholarship funds under the National Health
Service Corps Scholarship Program (Section 751 of the Act) or
the Scholarship Program for First-Year Students of Exceptional
Financial Need (Section 758 of the Act), you are not eligible
to participate in the IHS Scholarship Program during the school
year(s) for which these scholarships were awarded.

Veterans Benefits
You may continue to receive education benefits from the
Veterans Administration (G.I. Bill) along with IHS scholarship
funds since VA benefits were earned by prior active duty in a
uniformed service.

Benefits From State, Local and
Other Federal Sources
If you owe an obligation for professional practice to a state or
other entity under an agreement made before applying for IHS
scholarship funding, you are not eligible for an award unless
the state or entity submits to the Secretary a written statement
which says:
» There is no potential conflict in fulfilling your service obligation to the state or entity and the IHS Scholarship Program,
and
» The IHS Scholarship Program service obligation will be served
before or concurrently (if applicable) the service obligation
for professional practice owed to the state or entity.

How to Apply

This handbook contains a complete set of IHS Scholarship
Program application forms. If you need additional forms or
handbooks, please download them from our Web site, or if you
have any questions, please contact the program.
IHS Scholarship Program
801 Thompson Avenue, Suite 120
Rockville, Maryland 20852
Scholarship Branch Phone: (301) 443-6197
Division of Grants Operations Phone: (301) 443-0243
www.scholarship.ihs.gov

Application Deadline
The application deadline is March 28. Late applications will
not be considered for funding. Applications are considered
to have met the deadline if they are received by the IHS
Scholarship Program office:
Hand-carried — On or before the deadline date when
received by close of business (5:00 pm), or
Mailed/Other Service — Postmarked on or before the
deadline date and received in time to be reviewed along
with all other timely applications. A legible, dated receipt
from a commercial carrier (such as FedEx or UPS) or the
US Postal Service will be accepted in lieu of a postmark.
Private metered postmarks will not be accepted as proof of
timely mailing.

4. Documentation of American Indian/
Alaska Native Eligibility
Submit a copy of an approved Bureau of Indian Affairs (BIA)
Certification Form 4432. Use Category A for American Indian:
Members of Federally Recognized Tribes, Bands or Communities,
and Category D for Alaska Native.

5. Official Transcript
Provide one original official transcript from each college and
university attended. Official transcript means the institutional
seal and/or the signature of the registrar must be present. If
you have not attended a college or university, submit official
high school transcripts. If you did not graduate from high school,
submit a copy of an official document verifying completion of
high school equivalency. The cumulative grade point average
will be determined from the official transcript(s). The GPA is one
of the factors included in your final application rating.

6. Proof of Acceptance
Provide written evidence of acceptance into school, such as an
original Letter of Acceptance, or, if applicable, a letter indicating
continuing eligibility for enrollment for the fall/spring academic
year for which you’re applying for academic support, signed by
an appropriate school official.
Health Preparatory and Pre-Graduate program applicants
— requires only a general acceptance into school for the
fall/spring academic year in which you’re applying for scholarship support.

Your complete application consists of the following:

Health Professions program applicants — requires a specific
letter of acceptance (most current) into the specific health
category. A letter of general admission to a school is not
acceptable and will cause your application to be considered
incomplete.

1. Application Checklist

7. Reasons for Requesting Scholarship Form

Complete Application

Include your completed checklist with original signature.

2. Application Form
The form must be completed, signed and dated. New applicants
must complete Form IHS856. Important: You must include the
date, month and year of your graduation.

3. Two Faculty/Employer Recommendations
(Attachment II)

8. Delinquent Federal Debt Form
9. W-4 Form
Must have original signature.

10. Verification of Course Curriculum Form
(Attachment I)
Must be signed by an appropriate official.

11. Curriculum for Major
12. Part-Time Status Documentation
For part-time applicants, include documentation that your
professional school or program and course curriculum allow less
than full-time status.

13. Copy of Application Packet
Include with your original application packet a copy of the
original application packet in its entirety.

14. Acknowledgement Card
This is optional, to let you know that your application has
been received.

Important Reminders
Before submitting your application, make sure that you:
» Submit documents with original signatures. All documents submitted with this application must have the original
signatures to be valid.
» Submit official transcripts. All transcripts must be official to
be valid.
» Submit proof of enrollment/acceptance. Include current
written evidence of your letter of acceptance into the
school/program for the academic year for which you are
requesting scholarship support.
» Submit official evidence of Tribal membership. A Certificate of Indian Blood (CIB) alone is not enough for acceptance.
You must provide official evidence of Tribal membership.
» Submit a Form W-4 (for the current year). You must
submit a Form W-4 for the current scholarship year with the
application for it to be complete.
» Submit your curriculum. Include the entire curriculum for
the major in the scholarship for which you are applying.
» Fill out Form IHS-856. Be sure to fill out the bubble sheet,
Form IHS-856, completely in No. 2 lead pencil. Sign and date
it in ink.
» Include a copy of your application. Submit a copy of the
original application packet in its entirety, in addition to
submitting the original application packet in its entirety.

Step-by-Step Instructions

Step-by-Step Instructions
Instructions for the Academic Year
2008-2009 Application Checklist

Within the following pages, you will find detailed instructions
for completing your IHS Scholarship Program application. The
checklist is included to assist you in preparing your application
and to ensure that it is complete. Check off each item as you
complete it and gather the documentation required. Return the
completed checklist along with your completed application.
Beginning with the boxes above the checklist, fill in your name,
career category, Social Security number and the name of the IHS
office through which you are applying for the scholarship. If you
have ever received an IHS scholarship or grant, check the “YES”
box, then note the career category of your scholarship or grant,
and indicate which section (scholarship or grant) it is in.
In the next box, check the specific scholarship for which you
are applying. If you are a continuing student, please refer to
the Student Handbook for instructions on how to apply for
continuation.

All scholarship applicants must fill out the required forms and
provide the necessary documentation for the first 12 items on
the checklist. The last item is to be completed only by Master
of Public Health (MPH) applicants for the Health Professions
Scholarship. The Health-Related Experience form is where you
can document any experience you might have in a health field.
Filling it out is optional.
Each item of the checklist is explained in detail in the
following sections.
Include your signed and dated Application Checklist form
with your completed application. Be sure you have checked
off all applicable items on the form before submitting the
complete package.

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

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
ACADEMIC YEAR 2008-2009 APPLICATION CHECKLIST

See Estimated Average Burden Time
per Response on Reverse Side.

The applicant must complete and forward this sheet with the application and required documents.
Please check the appropriate box for each document which is enclosed.
APPLICANT’S NAME

CAREER CATEGORY

SOCIAL SECURITY NUMBER

INDIAN HEALTH SERVICE OFFICE APPLYING THROUGH

HAVE YOU EVER RECEIVED AN IHS SCHOLARSHIP OR GRANT?
If “Yes”, enter below:
CAREER CATEGORY

TYPE OF APPLICATION:

Yes

SECTION
New
Continuing
Health Preparatory
Pregraduate

Health Professions

ALL APPLICANTS:

NEW

1. Application Checklist ...................................................................................................
2. Application Form IHS-856 (Continuation Students – Data Sheet) .............................
3. Letter of Acceptance from College/Proof of Application to
Health Professions Program (Applicable to continuation
students who are transferring schools, changing from
103/103P to 104, or changing disciplines) ..................................................................
4. Official Transcripts for All Colleges
Cumulative GPA: Applicant’s Calculation: ______ ......................................................
5. Documentation for American Indian/Alaskan Native Eligibility ...................................
6. Two Faculty/Employer Evaluations with original signatures .......................................
7. Reason for Requesting Scholarship ...........................................................................
8. Delinquent Debt Form .................................................................................................
9. W-4 Form with original signature ................................................................................
10. Course Curriculum Verification with original signature (If part-time—
minimum of six credit hours) .......................................................................................
11. Acknowledgment Card ................................................................................................
12. Curriculum for Major ....................................................................................................

HEALTH PROFESSIONS APPLICANTS ONLY:
13. Health Related Experience (MPH Only) – Optional Form ............................

I verify the application is complete.
APPLICANT’S SIGNATURE

IHS-856-2
(Rev. 5/07)

DATE

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).

Instructions for Checklist Line 2

Section A – General

Application Form IHS-856 (Bubble Sheet)

This section covers general applicant information, including
personal data and your Tribal information.

Please read all instructions before making any entries on the
application. Errors or omissions on the form will delay or prevent
the processing of your application. The application IHS Form-856
(bubble sheet) must be filled out using a No. 2 lead pencil.
Do not use a ballpoint pen or any other type of pen. Do not
fold or bend this form, staple it or deform it in any way.
You will record your information two ways:
» Print the required information in the boxes above the
columns of bubbles, or circles. Begin in the first box of each
set and print only one letter per box.
» Blacken the appropriate circle for each letter, number, symbol
or empty space in the column directly beneath a box that
you’ve written in. Fill in the empty circles above row A only
for spaces that you have left intentionally blank between
words.
When completing the form, take care to:

Line 1 – Discipline or Prerequisite Track
Enter the name of your program and fill in the corresponding
two- or three-letter code in the boxes, then blacken the appropriate circles in the columns below it. The table below contains
the program names and codes. If your program is not listed
here, you are not eligible for an IHS scholarship.
Health Professions Preparatory:
PCP
PDI
PEN
PMT
PNU
POC
PPH
PPT
PSN
PSW

Pre-Clinical Psychology
Pre-Dietetics
Pre-Engineering
Pre-Medical Technology
Pre-Nurse
Pre-Occupational Therapy
Pre-Pharmacy
Pre-Physical Therapy
Pre-Sanitarian
Pre-Social Work

» Answer all questions.
» Fill in the circles completely, making your marks dark
and heavy.
» Stay within the circles. If you must erase stray marks or
incorrect entries, be sure to erase completely.

Health Professions Pre-Graduate:
PDD
PMD
PPY

Pre-Dentistry
Pre-Medicine
Pre-Podiatry

Health Professions Scholarship:
ADA
ADN
CP
CS
DD
DH
DI
DO
ENG
GER
HCA
HE
HRC
IPS
MD
MDT
MPH
NA

Chemical Dependency Counseling
Associate Degree Nurse
Clinical Psychologist
Coding Specialist (Certificate)
Dentist
Dental Hygiene
Dietician
Physician, Osteopathic
Engineering
Geriatric Nursing
Health Care Administration
Health Education
Health Records
Injury Prevention Specialist
Physician, Allopathic
Medical Technology
Master of Public Health (MPH)
Registered Nurse Anesthetist (CRNA)

NP
NU

OCT
OPT
PA
PED
PH
PHN
POD
PSY
PT
PTA
RT
SAN
SON
SW
WH
XRY

Nurse Practitioner
Nurse, with a minimum of a BS
in Nursing (BSN)
Occupational Therapy
Optometrist
Physician Assistant
Pediatric Nursing
Pharmacist
Public Health Nutritionist
Podiatrist
Psychiatric Nursing
Physical Therapist
Physical Therapy Assistant
Respiratory Therapist
Environmental Health (Sanitation)
Ultrasonagrapher
Social Worker
Women’s Health Nursing
Radiology Technology

Example: A scholarship applicant is pursuing a degree in
nursing (BSN). To fill in the form correctly:
1. Find the program name “Nurse”.
2. Write the code “NU” in the boxes.
3. Blacken the “N” circle in the first column under the letter
“N” you have entered, and blacken the “U” circle in the next
column under the letter “U” you have entered.

Line 2 – Your Full Name
Enter your first and middle names, with one space between the
them, in the appropriate section of boxes, and your last name
in the next section of boxes. Blacken the corresponding circles,
including one for the space between your first and last names.
If your name contains a suffix, such as junior (Jr.), senior (Sr.),
II (the second) and so on, blacken the appropriate circle in the
box to the right of the name sections.

Line 3 – Street Address Only

Line 7 – Email Address

Enter your street name and number only in this section. Blacken
the appropriate circles below the boxes. Do not enter the City,
State and ZIP Code here. You will do that in the next section. If
you do not require a second line for your street address, leave
that section of boxes blank.

Your email address will be the primary form of communication,
so enter an address that you check frequently. Blacken the
corresponding circles. Note that symbols often used in email
addresses, such as “@”, “.”, “-” and “_” are the bottom four
rows of circles. If you do not have an email address, leave this
area blank.

Line 4 – City, State and ZIP Code
Line 4a – City Only
Enter the name of your city only in this section. Blacken the
corresponding circles below the boxes.
Line 4b – State
Blacken the corresponding circle for your state (includes territories and protectorates).
Line 4c – ZIP Code
Enter your ZIP Code in the boxes and blacken the corresponding
circles below them.

Line 8 – Place of Birth
Print the city and state or country of birth in the boxes, and
blacken the corresponding circles.

Line 9 – US Citizenship
If you are a citizen of the United States, blacken the “YES”
circle. Only US citizens or naturalized citizens are eligible for IHS
scholarship awards.

Line 10 – Are you Eligible?

If you do not know your ZIP+4 code, leave the last four columns
blank and enter only the five-digit ZIP Code.

Those eligible will be required to show the following proof
when applying:

Line 4d – Area Office Code
Write the two-digit numeric code for your IHS Area in the boxes
and blacken the corresponding circles.

BIA Certification: Form 4432, as follows:

Line 5a – Home Phone Number
Enter your area code and home phone number and blacken the
corresponding circles.

Line 5b – Daytime Phone Number
Enter your daytime phone number. If this number is the same
as your home phone number, please enter it again here.
Blacken the corresponding circles.

Line 6 – Social Security Number
Enter your Social Security number and blacken the appropriate
circles. You are asked to provide your Social Security number on
a voluntary basis. However, if you do not provide this information and you are awarded a scholarship, you will be required
at that time to provide it for purposes of payroll and payments
to you of scholarship benefits. For more information, see the
Privacy Act Notice in this handbook. The number is used for
identification purposes only. If you do not have a Social Security
number, you should make immediate efforts to obtain one by
calling your local office of the Social Security Administration.

» American Indian: Category A — Members of Federally
Recognized Tribes, Bands or Communities
» Alaska Native: Category D — Alaska Native
Please refer to the section on Documentation of American
Indian/Alaska Native Eligibility for exceptions and a detailed
explanation of the documentation required.

Line 11 – Tribal Code
This section is for use by the IHS Scholarship Program office
only. Applicants should leave this section blank.

Line 12 – Tribal Recognition
Blacken the circle that describes your Tribal recognition:
1. Your Tribe is federally recognized
2. Your Tribe is state-recognized
3. You are a descendent of a federal or state tribe, or both
Only if your Tribe is state-recognized, fill in the boxes with the
phone number and address of your State Attorney General’s
office or the Commissioner of Indian Affairs.

Line 13 – Recipient of EFN Scholarship
If you are a recipient of financial support under the Scholarship
Program for First-Year Students of Exceptional Financial Need
(EFN), blacken the “YES” circle. Preferential consideration is
given to otherwise eligible applicants who are previous recipients of EFN scholarships. If you select “YES”, you must submit
a letter of verification from an official at the school where you
received the scholarship. Please contact the Grants Management Office if you have additional questions.

Line 14 – Previous Service Commitment
If you are currently under any obligation to practice your profession in a state or other entity after you complete your training,
this could conflict with the service obligation you incur under the
IHS Scholarship Program. If you are obligated to practice under
another program, read the terms of your agreement with that
program carefully. Such an obligation does not necessarily make
you ineligible for the IHS Scholarship Program, as many service
agreements will allow you to serve the IHS Scholarship Program
service obligation first. If this is your case, there is no conflict
and you should answer “NO”.
If you are not currently under any service obligation to another
program, answer “NO”.

Line 15 – Future Specialty Interest
Print the name of the specialty you are planning to pursue. Find
the matching code from the list below, enter it in the boxes and
blacken the corresponding circles in the specialty code blocks.
If you do not have a specialty preference at this time, enter the
word “UNKNOWN” in the box and blacken the corresponding
circles. Note: All residencies require prior approval.
Family Practice
Child Psychiatry
Emergency Medicine
General Psychiatry
General Surgery
Obstetrics/Gynecology
Pediatrics
Internal Medicine
Nurse Practitioner

FP
CPSY
EM
GPSY
GSUR
OBGYN
PED
INT
NP (Master’s Level Only)

NP Specialty, if applicable:
Acute Care
Adult Health
Family Health
Gerontology Health
Neonatal Health
Oncology

AC
AH
FH
GH
NH
ONC

Pediatric/Child Health
PCH
Psychiatric/Mental Health PMH
Women’s Health
WH

Line 16 – Permanent Contact Person
Print the name, permanent address and phone number of a
person through which you can always be contacted and that
will not change, such as a parent, relative or close friend. Your
scholarship stipends will be paid by direct bank deposit and this
information will not be changed during your entire first year of
scholarship funding. You will not be allowed to change banks
unless you change schools and relocate to another city.

Line 17 – W-4 Form
(Employee’s Withholding Allowance Certificate)
Your application packet includes an Internal Revenue Service
(IRS) Form W-4 that you must complete and submit with your
application. IHS Scholarship funds are subject to federal income
tax, and possibly state and local taxes. IHS withholds federal
income taxes only from your stipend checks. Please inquire
in your state about any state tax liability on your award. For
instructions concerning allowances, exemptions and filing
status, refer to the W-4 form for the current year — see form
section.
On the IHS-856 Form (bubble sheet), you will supply some of
the information that you entered on the W-4 form by blackening the corresponding circles. For lines 17a through 17d,
provide the following information:
Line 17a – Your marital status for withholding federal
income taxes.
Line 17b – The total number of withholding allowances you are
claiming (up to seven).
Line 17c – If you are claiming exemption from withholding.
Line 17d – Specify any additional amount you would like to be
deducted each pay period. If you want additional deductions,
state this amount in whole dollars. You must enter a numeral
in all three boxes and blacken the corresponding circles. For
example, if you want $30 deducted, enter “030” in the boxes
and blacken the circles for “030” or if you want $0 deducted,
enter “000” in the boxes and blacken the circles for “000.”
If you do not wish tax withheld from your monthly stipend
check, you should claim “exempt” on the W-4 form and skip
line 17b.

Section B – Degree Program
In this section, you will answer questions that pertain only to
the scholarship for which you are applying.

Line 1 – Enrollment Status
Select full-time or part-time. In the boxes, enter the average
number of credit hours you will be enrolled in for the term,
quarter or semester. Full-time status is 12 or more credit hours.
Part-time status is six to 11 credit hours. Blacken the corresponding circles.

Line 2 – School Name
Print the name of your school in the box, and blacken in the
corresponding circles.

Line 3 – School Location
Print the city and state where your school is located, and
blacken the corresponding circles.

Line 4 – School Code
This section is for use by the IHS scholarship program office
only. Applicants should leave this section blank.

Line 8 – For Health Professions Scholarship
Applicants Only
Select the year of health professions coursework you will be
enrolled in during the academic year for which you are applying
for a scholarship.

Line 9 – Previous College or University Attendance
College or University
If you have attended college or graduate school, provide information on your attendance. Enter the name of your school(s),
the appropriate city and state, the month and year you
attended, the number of credit hours you completed, the type
of degree you obtained, and the month and year you obtained
the degree (if applicable). If you are graduating within six
months of the application, enter the degree you will obtain and
the month and year you expect to graduate. Submit with your
application official transcripts from each college or university.
High School or GED
If you have not attended college, complete this set of boxes to
provide information on your high school attendance or GED high
school equivalency. Enter the name and location of your high
school, or where your GED was obtained. Enter the month and
year you attended, and your graduation date, or the date you
were awarded your GED certification.

Line 5 – Date of School Attendance
Enter the month and year you first attended or will attend
school. Blacken the corresponding circles.

Line 6 – School Tuition Charge Status
Select the category in which you will be charged tuition and
fees for the school year that you’re applying for scholarship
assistance. If your school charges the same tuition and fees
for in-state residents and out-of-state non-residents, select the
third choice. Blacken the corresponding circle.

Line 7 – Specific Scholarship
Line 7a – Select the scholarship for which you are applying.
Line 7b – This line is extremely important. Enter the month
and year you expect to graduate, or the month and year you
expect to complete the required coursework. Select “June” if
you cannot confirm your graduation month. Blacken in the
corresponding circles.

Section C – Miscellaneous
Line 1 – Date of Birth
Enter the month, day and year of your birth in this format:
02-05-74 (for February 5, 1974, for example). Blacken the
corresponding circles under the boxes.

Line 2 – Gender
Blacken the appropriate circle for your gender.

Line 3 – Permission to Receive Additional
Funding Information
If you are not selected to receive a scholarship, IHS would
like permission to forward your application to other potential
funding sources, including other government agencies, nongovernmental sources and Tribal sources. Select “YES” if you
would like IHS to do this, or “NO” if you would not.

Line 4 – Grant Number
This section is for use by the IHS Scholarship Program office
only. Applicants should leave this section blank.

Section D – Certification
In this section, you will certify that the information you have
given is accurate and complete to the best of your knowledge.
The information you provide might be investigated, and any
willful misrepresentation will be cause to reject your application for an IHS scholarship award. If a scholarship has been
awarded, willful misrepresentation will make you liable
for repayment of awarded funds. False statements may be
punished as a felony under US code, Title 18, Section 1001.
After you have read the certification statement on the application sheet and understand it fully, sign your full name and date
the application in ink in the boxes provided.

Checklist Line 3

Letter of Acceptance or Proof of Application to
Health Professions Program
New Applicants: You must submit proof of acceptance into
school, such as an original Letter of Acceptance. If you are
already attending school, submit a letter indicating that you
are eligible for enrollment in the fall/spring academic year for
which you are applying for scholarship support, signed by an
appropriate school official.
Health Preparatory and Pre-Graduate Applicants: a general
acceptance into school for the fall/spring academic year in
which you are applying for scholarship support will satisfy this
requirement.
Health Professions Applicants: You are required to submit a
specific letter of acceptance (the most current) showing you
have been accepted into your specific health category. A letter
of general admission is not acceptable.
If you have applied to more than one school and are awaiting
acceptance from any one of them, you must include letters
from all of the schools you have applied to stating that your
application for admission has been received. These letters
must include the date formal acceptance will be given if you
are accepted. If you submit such letters, you must follow up
with evidence of official acceptance to the school you choose
to attend as soon as you are informed of your acceptance. This
official acceptance must be received by IHS prior to the selection of students to be awarded (later dates of acceptance can
be considered on a case-by-case review and if there is documentation from the school to this effect).
If you have received letters of acceptance, include all of them
and all course curriculum verification forms.
Continuation Students:
Please refer to the Student Handbook for instructions.

Instructions for Checklist Line 4
Official Transcripts for all Colleges

You must submit official transcripts (not copies of transcripts)
for all colleges and universities you have attended. Official
transcript means the institutional seal and/or the signature
of the registrar must be present. If you have not attended a
college or university, submit official transcripts from your high
school. If you did not graduate from high school, submit a copy
of an official document that verifies high school equivalency.
On the checklist form, enter your current cumulative GPA in the
space provided on line 4.

Checklist Line 5

Documentation for American Indian/
Alaska Native Eligibility
Submit a copy of an approved Bureau of Indian Affairs (BIA)
Certification Form 4432 with your application (see page 14 of
this handbook for further details).

Form BIA 4432
Revised March 1989

United States Department of the Interior
BUREAU OF INDIAN AFFAIRS

VERIFICATION OF INDIAN PREFERENCE FOR EMPLOYMENT
IN BUREAU OF INDIAN AFFAIRS AND INDIAN HEALTH SERVICE ONLY
To Establish eligibility for Indian preference for employment with BIA/HIS, complete one of the categories below and submit with your OF-612,
Optional Application for Federal Employment

Category A

MEMBERS OF FEDERALLY RECOGNIZED INDIAN TRIBES, BANDS OR COMMUNITIES
This is to certify that the person named below is a member of the tribe indicated:
Full Name

Date of Birth

Tribal Affiliation

I certify the above information was taken from the official records of the
_________________________ Tribe and acknowledge that falsification and misrepresentation of
this information is punishable under Federal Law.
or
Tribal Representative

Title

Date

BIA Representative

Date

Title

Agency Name

Category B

DESCENDANTS OF MEMBERS OF FEDERALLY RECOGNIZED INDIAN TRIBES, BANDS
OR COMMUNITIES WHO WERE RESIDING ON ANY INDIAN RESERVATION ON JUNE
1, 1934.
This is to certify that the person named below has established to my satisfaction that he is a
descendant of an enrolled member of the tribe named below and that he was living on an Indian
reservation on June 1, 1934. The applicant’s family history is outlined on the attached family
history chart.

Name of Individual

Date of Birth

Reservation of Residence on June 1, 1934

Ancestor

Tribal Record of Affiliation

Date

BIA Representative

Title

Agency Name

Form BIA 4432
Revised March 1989

Category C

PERSONS WHO POSSESS AT LEAST ½ DEGREE INDIAN BLOOD DERIVED FROM
TRIBES INDIGENOUS TO THE UNITED STATES.
This is to certify that I have reviewed the documentation to support the below listed individual’s
claim to the possession of at least ½ degree Indian blood. The attached family history chart
outlines the individual’s family history.

Name

Date of Birth

Based on (name records)

BIA Representative

Degree of Blood and Tribal Derivation

Date

Title

Agency

Category D

PERSONS OF ESKIMO OR OTHER ABORIGINAL PEOPLES OF ALASKAN DESCENT
This is to certify that the person named below has established to my satisfaction that he is
qualified for Indian Preference because of his possession of Eskimo or other aboriginal peoples’
blood of Alaska. The attached family history chart outlines the individual’s family history.

Name

Date of Birth

Alaska Native Group

Record(s) on Which Based

BIA Representative

Title

Agency

Date

Checklist Line 6

Faculty/Employer Evaluations (Attachment II)
You are required to submit two completed faculty/employer
evaluations, with original signatures (Attachment II, form IHS856-4). You must use this form. A letter of recommendation
without this form is not acceptable. This is an important part
of the selection process, as these evaluations will be used to
determine your rating.

Provide these forms to faculty and employer personnel who can
evaluate your school/work performance. Collect the completed
forms and submit them with your application. Make sure the
forms are signed by the evaluator, including the Statement of
Conflict of Interest at the bottom of the form, certifying that the
evaluator isn’t related to you by blood or marriage.

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

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
FACULTY/EMPLOYER EVALUATION
STUDENT’S NAME

REGARDING

See Estimated Average Burden Time
per Response on Reverse Side.

SOCIAL SECURITY NUMBER

CAREER CATEGORY

EMAIL ADDRESS

The student identified above is applying to receive an Indian Health Service (IHS) Scholarship. The information on this
form is requested pursuant to Section 751-756 of the Public Health Service Act, as amended, and applicable program
regulations which provide that, in evaluating and selecting individuals for scholarships, consideration will be given to
faculty or employer recommendations.
The information provided on this form is treated as confidential and may only be disclosed outside the Department of
Health and Human Services in accordance with provisions of the Privacy Act of 1974 (P.L. 93-579) and the terms and
conditions of the applicable Privacy Act Notice published by the Department in the Federal Register.
PLEASE RETURN COMPLETED FORM TO APPLICANT

1. How do you rate the educational/work achievement of this applicant? (Please provide written comments.)
5OUTSTANDING

4ABOVE AVERAGE

3AVERAGE

2BELOW AVERAGE

0POOR

2. How do you rate the applicant’s relationships with other people?
Consider such things as ability to work and get along with others. (Please provide written comments.)
5OUTSTANDING

4ABOVE AVERAGE

3AVERAGE

2BELOW AVERAGE

0POOR

3. Based on this applicant’s personal, emotional, ethical attributes, how do you rate his/her over-all potential for
the practice of primary health care, especially in a health manpower shortage area?
(Please provide written comments.)
54320OUTSTANDING
ABOVE AVERAGE
AVERAGE
BELOW AVERAGE
POOR
Please provide written comments:

Type of work:
Length of time known:

Statement of Conflict of Interest: I certify I am not related to applicant by blood or marriage.
NAME (Print or type)

TITLE OF POSITION

IHS-856-4 (5/07)

SIGNATURE

DATE

PLACE OF EMPLOYMENT

ATTACHMENT II (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 50 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).

Checklist Line 7

Reasons for Requesting Scholarship
(Attachment III)
On this form (Attachment III, Form IHS-856-5), you’ll explain
why you’re requesting IHS scholarship support, state your career
goals, and describe how your career goals will help to meet
the health needs of Indian people. At the top of the form, fill
in your name, career category, Social Security number, email
address and the IHS office you are applying through.

This form is an important part of the selection process and
helps determine your ranking. Please take care to write the
narrative with correct grammar, clarity and organization. Type
or print legibly for readability — you will not be rated on material that cannot be read. If you need more space than the form,
you can continue writing on the back of the last page of this
application, or securely attach extra sheets of the same size as
this paper. Write your name and Social Security number on each
extra sheet.

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

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
REASONS FOR REQUESTING SCHOLARSHIP
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

Explain why you are requesting this scholarship **

State your career goals **

Explain how these goals will help to meet the health needs of the Indian people **

** If more space is required, use back of last page of application or full sheets, the same size as this page. Write on each sheet
your name and social security number. Securely attach all sheets to this application.
IHS-856-5
(Rev. 5/07)

ATTACHMENT III (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 45 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).

Checklist Line 8

Delinquent Federal Debt Form (Attachment IV)
The purpose of this form (IHS-856-6) is to determine if you
have any delinquent federal debt. This includes federal income
taxes, guaranteed or direct student loans, FHA loans and other
miscellaneous administrative debts. Delinquency is defined as
being more than 31 days past due on a scheduled payment
for direct and guaranteed loans. IHS doesn’t consider deferred
loans to be delinquent.
You must complete and sign this form, and include it with your
application. Fill in your name, career category, Social Security
number, email address and the IHS office through which you
are applying. Answer “YES” or “NO” to the question: Are you
delinquent on the repayment of any federal debt(s)?”

If you are delinquent on the repayment of any federal debt,
check “YES”. Write an explanation of your delinquent debt in
the space provided. Include the name of the federal agency
that you owe, the type of debt (such as student loan or HUD
mortgage, for example), the name and phone number of a
contact person handling your debt, and the account number.
Additionally, you must include a notarized power of attorney,
authorizing IHS Grants Management Branch personnel to inquire
on your debt. Your application will not be considered for an
award if you do not include this authorization. If you have any
questions regarding the power of attorney, contact the IHS
Grants Management Branch.

If you answer “NO”, sign and date the form at the bottom and
submit it with your application.

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

ATTACHMENT IV (Continued)

Checklist Line 9

Employee’s Withholding Allowance (W-4 Form)
IHS scholarship benefits paid to you are subject to federal
income tax. You must complete the Internal Revenue Service
(IRS) W-4 form in order to comply with tax withholding requirements in the event you are selected.

If you do want tax withholding, complete the W-4 form and
fill out the information requested in Section A of Form IHS-856
(bubble sheet), lines 17a through d. Return the W-4 with your
application.

If you do not want tax withheld from your monthly stipend
check, you should claim “exempt” on the W-4 form and do not
fill in line 17b, Section A of Form IHS-856 (bubble sheet).

If you have any questions regarding the W-4 form, contact your
local Internal Revenue Service office or visit the IRS Web site at
www.irs.gov.

Form W-4 (2007)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal income
tax from your pay. Because your tax situation
may change, you may want to refigure your
withholding each year.
Exemption from withholding. If you are
exempt, complete only lines 1, 2, 3, 4, and 7
and sign the form to validate it. Your
exemption for 2007 expires February 16, 2008.
See Pub. 505, Tax Withholding and Estimated
Tax.
Note. You cannot claim exemption from
withholding if (a) your income exceeds $850
and includes more than $300 of unearned
income (for example, interest and dividends)
and (b) another person can claim you as a
dependent on their tax return.
Basic instructions. If you are not exempt,
complete the Personal Allowances
Worksheet below. The worksheets on page 2
adjust your withholding allowances based on

itemized deductions, certain credits,
adjustments to income, or two-earner/multiple
job situations. Complete all worksheets that
apply. However, you may claim fewer (or zero)
allowances.
Head of household. Generally, you may claim
head of household filing status on your tax
return only if you are unmarried and pay more
than 50% of the costs of keeping up a home
for yourself and your dependent(s) or other
qualifying individuals.
Tax credits. You can take projected tax
credits into account in figuring your allowable
number of withholding allowances. Credits for
child or dependent care expenses and the
child tax credit may be claimed using the
Personal Allowances Worksheet below. See
Pub. 919, How Do I Adjust My Tax
Withholding, for information on converting
your other credits into withholding allowances.
Nonwage income. If you have a large amount
of nonwage income, such as interest or
dividends, consider making estimated tax
payments using Form 1040-ES, Estimated Tax

for Individuals. Otherwise, you may owe
additional tax. If you have pension or annuity
income, see Pub. 919 to find out if you should
adjust your withholding on Form W-4 or W-4P.
Two earners/Multiple jobs. If you have a
working spouse or more than one job, figure
the total number of allowances you are entitled
to claim on all jobs using worksheets from only
one Form W-4. Your withholding usually will
be most accurate when all allowances are
claimed on the Form W-4 for the highest
paying job and zero allowances are claimed on
the others.
Nonresident alien. If you are a nonresident
alien, see the Instructions for Form 8233
before completing this Form W-4.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
dollar amount you are having withheld
compares to your projected total tax for 2007.
See Pub. 919, especially if your earnings
exceed $130,000 (Single) or $180,000
(Married).

Personal Allowances Worksheet (Keep for your records.)
A

Enter “1” for yourself if no one else can claim you as a dependent
● You are single and have only one job; or
B Enter “1” if:
● You are married, have only one job, and your spouse does not work; or
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,000 or less.





C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or
C
more than one job. (Entering “-0-” may help you avoid having too little tax withheld.)
D
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return
E
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)
F
F Enter “1” if you have at least $1,500 of child or dependent care expenses for which you plan to claim a credit
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub 972, Child Tax Credit, for more information.
● If your total income will be less than $57,000 ($85,000 if married), enter “2” for each eligible child.
● If your total income will be between $57,000 and $84,000 ($85,000 and $119,000 if married), enter “1” for each eligible
G
child plus “1” additional if you have 4 or more eligible children.
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.)  H
● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
worksheets
● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs
exceed $40,000 ($25,000 if married) see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
that apply.
● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.



Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form

W-4

Employee’s Withholding Allowance Certificate

Department of the Treasury
Internal Revenue Service

5
6
7

OMB No. 1545-0074

Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.



Type or print your first name and middle initial.

Last name

Your social security number

Home address (number and street or rural route)

City or town, state, and ZIP code

4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. 

Single
Married
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

5
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
6
Additional amount, if any, you want withheld from each paycheck
I claim exemption from withholding for 2007, and I certify that I meet both of the following conditions for exemption.
● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here
7

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature
(Form is not valid
unless you sign it.)
8



Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date



9 Office code (optional) 10

Cat. No. 10220Q

Employer identification number (EIN)

Form

W-4

(2007)

Form W-4 (2007)

Page

Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions, claim certain credits, or claim adjustments to income on your 2007 tax return.
1 Enter an estimate of your 2007 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions. (For 2007, you may have to reduce your itemized deductions if your income
is over $156,400 ($78,200 if married filing separately). See Worksheet 2 in Pub. 919 for details.)
1 $
$10,700 if married filing jointly or qualifying widow(er)
2 Enter:
$ 7,850 if head of household
2 $
$ 5,350 if single or married filing separately
3 Subtract line 2 from line 1. If zero or less, enter “-0-”
3 $
4 Enter an estimate of your 2007 adjustments to income, including alimony, deductible IRA contributions, and student loan interest
4 $
5 Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 8 in Pub. 919)
5 $
6 Enter an estimate of your 2007 nonwage income (such as dividends or interest)
6 $
7 Subtract line 6 from line 5. If zero or less, enter “-0-”
7 $
8 Divide the amount on line 7 by $3,400 and enter the result here. Drop any fraction
8
9 Enter the number from the Personal Allowances Worksheet, line H, page 1
9
10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10





Two-Earners/Multiple Jobs Worksheet (See Two earners/multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $50,000 or less, do not enter more
than “3.”

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet
3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to calculate the additional
withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9

Enter the number from line 2 of this worksheet
4
Enter the number from line 1 of this worksheet
5
Subtract line 5 from line 4
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed
Divide line 8 by the number of pay periods remaining in 2007. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2006. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
$0
4,501
9,001
18,001
22,001
26,001
32,001
38,001
46,001
55,001
60,001
65,001
75,001
95,001
105,001
120,001

$4,500
9,000
18,000
22,000
26,000
32,000
38,000
46,000
55,000
60,000
65,000
75,000
95,000
- 105,000
- 120,000
and over

Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

If wages from LOWEST
paying job are—
$6,000
12,000
19,000
26,000
35,000
50,000
65,000
80,000
90,000
- 120,000
and over

All Others

Married Filing Jointly
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10

Privacy Act and Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United States. The
Internal Revenue Code requires this information under sections 3402(f)(2)(A) and
6109 and their regulations. Failure to provide a properly completed form will
result in your being treated as a single person who claims no withholding
allowances; providing fraudulent information may also subject you to penalties.
Routine uses of this information include giving it to the Department of Justice for
civil and criminal litigation, to cities, states, and the District of Columbia for use in
administering their tax laws, and using it in the National Directory of New Hires.
We may also disclose this information to other countries under a tax treaty, to
federal and state agencies to enforce federal nontax criminal laws, or to federal
law enforcement and intelligence agencies to combat terrorism.

$
$

Table 2
All Others

$0
6,001
12,001
19,001
26,001
35,001
50,001
65,001
80,001
90,001
120,001

6
7
8

If wages from HIGHEST
paying job are—
$0
65,001
120,001
170,001
300,001

- $65,000
- 120,000
- 170,000
- 300,000
and over

If wages from HIGHEST
Enter on
line 7 above paying job are—
$510
850
950
1,120
1,190

$0
35,001
80,001
150,001
340,001

- $35,000
80,000
- 150,000
- 340,000
and over

Enter on
line 7 above
$510
850
950
1,120
1,190

You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.

Checklist Line 10

Course Curriculum Verification (Attachment I)
This form (IHS-856-3) is to be completed and signed by
the appropriate official at the college or university you are
attending. The purpose is to verify that you have applied for
admission to the school or have enrolled for the upcoming
academic year.
Before giving the form to your school, fill in the information in
the four boxes at the top: your name, Social Security number,
your career category and your email address. In the fifth box,
check the specific scholarship for which you are applying. Next,
fill in the name of your school, and in the next sentence, circle
your status (full-time or part-time, printed in boldface). If you
are enrolling in a preparatory program, fill in the name of the
program in the blank space.

The next section provides spaces for you to list the coursework
you are planning to take for the academic year. For each
semester or quarter, write in the course number, the credit
hours and the course title. In the space to the right of each
section, fill in the total number of credit hours for the semester
or quarter.
Give the form to your college advisor or counselor, who must
sign and date the form, and provide their correct title and a
contact phone number. Obtain the completed form from your
school official and submit it with your application.
In addition, attach to the form a copy of your course curriculum
for your major from your school catalogue or major department
(see checklist line 12).

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

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
COURSE CURRICULUM VERIFICATION
STUDENT’S NAME

REGARDING
(Check one)

See Estimated Average Burden Time
per Response on Reverse Side.

SOCIAL SECURITY NUMBER

CAREER CATEGORY

EMAIL ADDRESS

HEALTH PROFESSIONS PREGRADUATE – Section 103(b)(2)
HEALTH PROFESSIONS PREPARATORY – Section 103(b)(1)
HEALTH PROFESSIONS – Section 104

THIS FORM MUST BE COMPLETED AND THEN SIGNED BY THE APPROPRIATE COLLEGE OR UNIVERSITY OFFICIAL

This verifies that the individual referenced above has applied for admission or is enrolled at (Name of
College/University) ____________________________________________________ for the academic year
2008-2009. He/She will be enrolled in either a full-time or part-time (circle one) undergraduate curriculum
leading to a bachelor’s degree in premedicine; or a preparatory curriculum which fulfills the requirement for
admission into his/her chosen health program of ___________________________ ; or the student is enrolled in
a health professional program that is eligible for funding under this scholarship program. The individual will be
enrolled/or is anticipated to be enrolled in the following courses commencing Fall 2008.

***ATTACH CURRICULUM FOR MAJOR FROM FIRST YEAR TO COMPLETION.***
SEMESTER I OR QUARTER I
COURSE NUMBER
CREDIT HOURS

TOTAL S/Q I HOURS: _____
COURSE TITLE

SEMESTER II OR QUARTER II
COURSE NUMBER
CREDIT HOURS

TOTAL S/Q II HOURS: _____
COURSE TITLE

QUARTER III
COURSE NUMBER

ADVISOR OR COUNSELOR SIGNATURE

PRINT NAME
IHS-856-3
(Rev. 5/07)

CREDIT HOURS

COURSE TITLE

TITLE

TOTAL Q III HOURS: _____

DATE

PHONE NUMBER

ATTACHMENT I (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 42 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).

Checklist Line 11

Acknowledgment Card
This form (IHS-815) is a postcard that IHS will mail back to you
within four weeks of receipt of your application. You should
retain this card in your records. Enter your name and address on
the front of the card and submit it with your application.

Checklist Line 12
Curriculum for Major

The curriculum for major is related to checklist line 10,
Course Curriculum Verification. You will need a copy of the
course curriculum for your major. This can usually be obtained
from your school catalogue or your majors department office.
Attach the Curriculum for Major to the Course Curriculum
Verification form.

Checklist Line 13

Health Related Experience (Attachment V)
For MPH Candidates Only (This Form is Optional)
To be considered for a scholarship for a Master of Public Health
(MPH), you must have a degree in a health-related discipline
and be accepted into an MPH program. This form (IHS-856-7) is
optional and is provided for you to document any health-related
or volunteer job experience you might have. Fill in your name,
career category, Social Security number, email address and the
IHS office through which you’re applying.
For each individual job, and beginning with your most recent
work experience, provide the exact title of your position, the
dates you were employed (month and year), the average
number of hours you worked per week, and your job status
(paid or volunteer). Next, describe your specific duties, responsibilities and accomplishments in this position. Submit this form
with your application.

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

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
JOB EXPERIENCE (MPH Students Only) [Optional]
NAME OF APPLICANT
SOCIAL SECURITY NUMBER

See Estimated Average Burden Time
per Response on Reverse Side.

CURRENT CAREER CATEGORY
EMAIL ADDRESS

INDIAN HEALTH SERVICE OFFICE APPLYING THROUGH

HEALTH RELATED JOBS OR VOLUNTEER EXPERIENCE (BEGIN WITH MOST RECENT WORK EXPERIENCE)

A. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

B. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

C. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

D. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

E. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

IHS-856-7
(Rev. 5/07)

ATTACHMENT V (Continued)

Additional Forms

Verification of Acceptance or Decline of Award
(Attachment VI)
Do not mail this form with your application! Retain it until
you are notified if you have been selected for a scholarship
award. This form (IHS-856-8) is to be used to accept or decline
and IHS scholarship award. If you are notified that you have
been selected, fill out the form, check the box for “ACCEPT” or
“DECLINE”, and return the form immediately to the address at
the bottom of it.

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

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
VERIFICATION OF ACCEPTANCE OR DECLINE OF AWARD

See Estimated Average Burden Time
per Response on Reverse Side.

RETAIN THIS ATTACHMENT UNTIL YOU ARE NOTIFIED OF YOUR
SELECTION AS A SCHOLARSHIP RECIPIENT.
DO NOT MAIL THIS FORM WITH YOUR APPLICATION SUBMISSION.

STUDENT’S NAME

SOCIAL SECURITY NUMBER

INDIAN HEALTH SERVICE OFFICE APPLYING THROUGH

EMAIL ADDRESS

REGARDING

Please indicate your acceptance or decline of an Indian Health Service Scholarship award by checking the
appropriate space below. Scholarship award will not be issued until this form is completed and returned.
I accept the scholarship award for the 2008-2009 school year.
I decline the scholarship award for the 2008-2009 school year.
If you accept the award, you must immediately provide us below with your permanent recipient mailing
address to which correspondence will be sent during the entire first year of scholarship funding.

Please complete the following information.
POST OFFICE BOX NUMBER / STREET ADDRESS
CITY

STATE

ZIP CODE

Please note this is a change of address:
Complete this form and return immediately to:
Indian Health Service
801 Thompson Avenue, Suite 450
ATTN: Grants Scholarship Coordinator
Rockville, Maryland 20852
If you have any questions, please contact your Area Scholarship
Coordinator.
RETAIN THIS ATTACHMENT UNTIL YOU ARE NOTIFIED OF YOUR
SELECTION AS A SCHOLARSHIP RECIPIENT.
DO NOT MAIL THIS FORM WITH YOUR APPLICATION SUBMISSION.

Signature:
IHS-856-8
(Rev. 5/07)

Date:
EF

ATTACHMENT VI (Continued)

Your Health Career
Starts Here
INDIAN HEALTH SERVICE
801 Thompson Avenue – Suite 120
Rockville, Maryland 20852
Scholarship Branch Phone: (301) 443-6197
Division of Grants Operations Phone: (301) 443-0243

www.scholarship.ihs.gov

File Type	application/pdf
File Modified	2007-10-15
File Created	2007-10-09