10-264I Notice of Change and-or Academic Status

OMB Control No. 2900-XXXX
Estimated Burden: 20 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

NOTICE OF CHANGE AND/OR ANNUAL ACADEMIC STATUS

(Please submit this form for any changes from the original application and annually to verify academic status.)
THE PAPERWORK REDUCTION ACT OF 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore, we may not conduct or
sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form
will average 20 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out the form.
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 CFR, sections 17.545 through 17.553 (RCSSP) in order for VA to determine
the applicant's eligibility to receive a scholarship award. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information
for: civil or criminal law enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the
administration of VA training and scholarship programs, including verification of the applicant's eligibility to participate; and personnel administration. You do not have to provide this information
to VA but, if you do not, VA may be unable to process the applicant's request for a scholarship. If you give VA a social security number, VA will use it to obtain information relevant to
determining whether to grant a scholarship, and to administer the applicant's scholarship, if awarded. It also may be used for other purposes authorized or required by law.

RCSSP

Annual Status/Progress Report

Notice of Change
SSN (Last 4 Only):

Scholarship Participant's Name (Last, First, Middle):
I am still enrolled in the school/program for which this scholarship was awarded and do not
have any changes to my original application/academic plan or previously approved changes.

(Attach a copy of your current transcript or grade report)
Name Change

From:

Address Change

New Address:

Changes to my original application/academic plan are
indicated below.

To:

Supporting documentation is required for any changes identified below (new school fee schedule, etc.)
More than one change may be selected.
Completion Date Change

Credit Hour Change

From
(MM/DD/YYYY):

To
(MM/DD/YYYY):

From
(MM/DD/YYYY):

To
(MM/DD/YYYY):

Course Change (List below)
Previously Scheduled
Semester/
Quarter
Course #

New Schedule

Start Date
(MM/DD/YYYY):

End Date
(MM/DD/YYYY):

Course Title

Credits

Tuition

Semester/
Quarter
Course #

Start Date
(MM/DD/YYYY):

End Date
(MM/DD/YYYY):

Course Title

Total

Credits

Tuition

Total

Repeat Previously Failed Coursework Course #:

Course Title:

Change in Total Projected Costs

From
(MM/DD/YYYY):

To
(MM/DD/YYYY):

Academic Probation (MM/DD/YYYY):

Request for Suspension

Start
(MM/DD/YYYY):

End
(MM/DD/YYYY):

Leave of Absence

Start
(MM/DD/YYYY):

End
(MM/DD/YYYY):

Dismissed from
School
USMLE Step 1
Passed
USMLE Step 2
Passed

Change from full-time status to less then full-time status

Date
(MM/DD/YYYY):

Voluntary withdrawal from course(s) during an academic term

Date
(MM/DD/YYYY):

Date

Date
(MM/DD/YYYY):
Date
(MM/DD/YYYY):
Date
(MM/DD/YYYY):

School/Program change (Requires prior approval. Changes are strongly discouraged.) Date (MM/DD/YYYY):
New School/Program:
Reason for change(s) and planned actions other than change(s) noted above:

Date (MM/DD/YYYY):

Participant's Signature:
Advisor comments:

Date (MM/DD/YYYY):

Advisor's Signature:
Annual enrollment and satisfactory status/progress verified:

Advisor Disposition on proposed change(s)/actions:

Concur

Do not concur

Submit to: RCSSP, Department of Veterans Affairs, Readjustment Counseling Service (10RCS),
810 Vermont Ave., NW, Washington, DC 20420
VA FORM
NOV 2021

10-264I

10RCS

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