Fillable Printable VA Form 10-0491i
Fillable Printable VA Form 10-0491i
VA Form 10-0491i
Semester/QuarterSemester/Quarter
Advisor comments:
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
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.)
OMB Number: 2900-0793
Estimated Burden: 20 minutes
Scholarship Participant's Name (Last, First, Middle):
SSN:
Annual Status/Progress Report
Notice of ChangeVIOMPSP
HPSP
Participant's Signature: Date
Reason for change(s) and planned actions other than change(s) noted above:
Advisor's Signature: Date
Do not concurConcurAdvisor Disposition on proposed change(s)/actions:
Name Change
From:
Address Change
Completion Date Change
To:
Credit Hour Change
Change in Total Projected Costs
Repeat Coursework
Leave of Absence
Request for Suspension Dismissed from School
Academic Probation
Change from full-time status to less then full-time status
Voluntary withdrawal from course(s) during an academic term
School/Program change (Requires prior approval. Changes are strongly discouraged.)
New Address:
From: To:
From: To:
From: To:
Start: End:
Start: End:
Date:
Date:
Date:
Date:
Course Change (List below)
New School/Program:
Submit to: HPSP/VIOMPSP, Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113
Date:
Course #
Course Title
Course #
Course Title
Course #: Course Title:
Start Date
End DateStart DateEnd Date
Total Total
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)
Changes to my original application/academic plan
are indicated below.
Supporting documentation is required for all changes (new school fee schedule, etc...) More than one change may be selected.
New SchedulePreviously Scheduled
Annual enrollment and satisfactory status/progress verified:
Credits Tuition
Credits Tuition
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PRIVACY ACT NOTICE
The VA is asking you to provide the information on this form under the authority of 38 U.S.C. 7502 and 7602 in order for VA to administer your 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 your 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 continue your scholarship award. If you give VA your social security number, VA will use it to obtain
information relevant to administering your scholarship award. It also may be used for other purposes authorized or required by law.
10-00491I
DEC 2013
VA FORM
