Fillable Printable Public Law 94-437 – Title I Scholarship Program ...
Fillable Printable Public Law 94-437 – Title I Scholarship Program ...
Public Law 94-437 – Title I Scholarship Program ...
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE
PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM
CHANGE OF NAME OR ADDRESS
FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 3/31/2020
See Estimated Average Burden Time
per Response on page 2.
RECIPIENT’S NAME DEGREE PROGRAM
ADDRESS PHONE: CELL HOME
IHS AREA OFFICE EMAIL ADDRESS
INDICATE THE CHANGE YOU WOULD LIKE TO MAKE: NAME ADDRESS
NEW NAME:
If you have officially changed your name, you must attach the appropriate legal documentation
(for example, 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 State Zip Code
NEW PHONE: Cell Home
DATE OF CHANGE:
CHECK THE APPROPRIATE BOX:
I am enrolled in an undergraduate/graduate degree program.
I am completing an IHS-approved post-graduate clinical training program.
I am fulfilling my service commitment.
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):
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, Scholarship Program, 5600 Fishers Lane,
Mail Stop: OHR (11E53A), Rockville, MD 20857.
