Fillable Printable Lost Stipend Payment
Fillable Printable Lost Stipend Payment
Lost Stipend Payment
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE
PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM
LOST STIPEND PAYMENT
FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 3/31/2020
See Estimated Average Burden Time
per Response on page 1.
RECIPIENT’S NAME DEGREE PROGRAM
ADDRESS PHONE: CELL HOME
IHS AREA OFFICE EMAIL ADDRESS
Attention Grants/Financial Management:
I did not receive my Electronic Funds Transfer (EFT) in the amount of $ for
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:
Indian Health Service
Scholarship Program
5600 Fishers Lane
Mail Stop: OHR (11E53A)
Rockville, MD 20857
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, Scholarship Program, 5600 Fishers Lane,
Mail Stop: OHR (11E53A), Rockville, MD 20857.
