ihs form 856-9

PUBLIC LAW 94-437 STUDENT HANDBOOK

LOST STIPEND CHECKS / DIRECT DEPOSIT

IHS-856-9

LOST STIPEND CHECK / DIRECT DEPOSIT

(Rev. 5/07)

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

See Estimated Average Burden Time
per Response on Reverse Side

IHS Division of Grants Operations
Grants Scholarship Coordinator
801 Thompson Avenue - TMP Suite 450
Rockville, Maryland 20852
Attention Grants/Financial Management:
I did not receive my Electronic Transfer of Funds in the amount of $________________ for the
month __________________. I believe the ETF was not received for the following reason:
________________________________________________________________________________
_______________________________________________ ______________________ _______ __ .
Please trace and reissue as soon as possible.
Name: ___________________________________
Address: ___________________________________
___________________________________
___________________________________
___________________________________
Telephone and/or
Cell Phone Number: ___________________________________
Social Security Number: ___________________________________
EMail Address: ___________________________________

______________________________________ Signature (Do Not Print)

Please return a completed IHS-856-9 form to IHSSP, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852.

LOST STIPEND CHECKS / DIRECT DEPOSIT

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-9

(Rev. 5/07)

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 displays 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, RE: PRA 0917-0006.