Form IHS-856-22 Change of Name or Address

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

Change of Name or Address
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: Cell

CAREER CATEGORY

IHS AREA OFFICE

Indicate the change you would like to make:

Home

EMAIL ADDRESS

Name

Address

New Name:
If you have officially changed your name you must attach the appropriate legal documentation.
(e.g., marriage certificate).
If you are changing your address, complete the section below. Please note that a change of address
that is processed after the 10th of the month will not take affect until the following month.
New AddresS:

City

NEW Phone:

Cell

State

Zip Code

Home

Date of Change:
Check the appropriate box:
I am enrolled in an undergraduate/graduate health or allied health professions program
I am completing an IHS-approved post-graduate clinical training program
I am fulfilling my service obligation

RECIPIENT’S SIGNATURE

DATE

Return to:
IHS Scholarship Program
Attn: Program Analyst
801 Thompson Ave., Suite 120
Rockville, MD 20852



Reviewed (IHS use only): 
Analyst, Branch Chief or Designee
IHS-856-22

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.