Form IHS-856-19 Lost Stipend Payment

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

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

See Estimated Average Burden Time
per Response on Reverse Side.

LOST STIPEND Payment
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

CAREER CATEGORY

PHONE: CELL

IHS AREA OFFICE

Home

EMAIL ADDRESS

Attention Grants/Financial Management:
for

I did not receive my Electronic Funds Transfer (EFT) in the amount of $
the month of

. I believe the EFT was not received for the following reason:
.

Please trace and reissue as soon as possible.

RECIPIENT’S SIGNATURE

DATE

Return to:
IHS Division of Grants Operations
Attn: Grants Scholarship Coordinator
801 Thompson Ave., Suite 120
Rockville, MD 20852



Reviewed (IHS use only): 
Grants Scholarship Coordinator
IHS-856-19

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 Scholarships Branch, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.