IHS-856-23 Request for Credit Validation

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

See Estimated Average Burden Time
per Response on Reverse Side.

Request for Credit Validation
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

CAREER CATEGORY

PHONE: CELL

IHS AREA OFFICE

Home

EMAIL ADDRESS

With the submission of this form I grant the IHS Scholarship Program permission to release
pertinent information from my file to a credit card company, bank, department store, etc.
If you would to limit the release information, indicate those entities to whom you wish to
have your information released.

RECIPIENT’S SIGNATURE

IHS-856-23

DATE

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 6 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, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.