Form IHS-856-7 Verification of Acceptance or Decline of Award

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

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx
See Estimated Average Burden Time
per Response on Reverse Side.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

VERIFICATION OF ACCEPTANCE OR DECLINE OF AWARD
APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CAREER CATEGORY

IHS AREA OFFICE

EMAIL ADDRESS

Please indicate your acceptance or decline of an Indian Health Service scholarship award by checking the
appropriate space below. Your scholarship award will not be issued until this form is completed and returned.

I accept the scholarship award for the 20

– 20

school year.

I decline the scholarship award for the 20

– 20

school year.

If you choose to accept this award, you must immediately provide us below with your permanent mailing address to
which correspondence will be sent during the entire first year of scholarship funding.
Please complete the following information.
STREET ADDRESS / POST OFFICE BOX NUMBER

CITY

STATE

ZIP CODE

Please note this is a change of address

Complete this form and return immediately to:

Indian Health Service

ATTN: Grants Scholarship Coordinator

801 Thompson Ave., Suite 120

Rockville, Maryland 20852

If you have any questions, please contact the IHS Division of Grants Operations office.

APPLICANT’S SIGNATURE

IHS-856-7

DATE

EF

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, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.