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.