ihs form 856-8

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

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

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)

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).