10-0491

Academic Verification—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Agency
VA
Revision
September 2026
Fillable fields
481
Pages
7
Official source
VA form page
Checked
October 20, 2026
Fill 10-0491 online
Page 1 of form 10-0491

VA Form 10-0491: HPSP and VIOMPSP Academic Verification

VA Form 10-0491 is the U.S. Department of Veterans Affairs Academic Verification for the Health Professional Scholarship Program (HPSP) and the Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP), listed under VHA on VA's form page. The form says it is part of the application package and is completed by the applicant's Dean/Program Director, Coordinator, or Administrator of the program of study at the academic institution.

The PDF is seven pages. Page 1 holds the Privacy Act notice, the burden statement, the applicant's Consent for Release of Information and the application information. Page 2 covers cumulative grade point average and the plan of study and projected costs, pages 3 to 6 hold eight term tables for courses and fees, and page 7 holds one certification for the applicant and one for the Dean or Program Director. It is a scholarship form for applicants and schools, not a Veterans benefit application.

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Top of page 1 of VA Form 10-0491: HPSP and VIOMPSP Academic Verification, as printed by VA

What's on VA Form 10-0491

Notices and consent

The Privacy Act notice citing 38 U.S.C. §7501 (VIOMPSP) and §7611 (HPSP), the burden statement, and the Consent for Release of Information with the applicant's signature and date.

Application information, items 1 to 16

Name, Social Security number, phone, email, institution, program of study, degree and specialty, expected degree, accrediting organization and its expiration date, enrollment status, the school's full-time definition, key dates and full-time or part-time attendance.

Cumulative grade point average

Undergraduate and graduate CGPA, the credits they are based on, semester or quarter or N/A, and for graduate students whether the student is in good academic standing. The form explains which courses the CGPA covers.

Plan of study and projected costs

Instructions for listing each term's courses, credit hours and projected tuition, which fees VA will pay, and a list of fee examples the form says VA will not reimburse or cover.

Term tables

Eight tables on pages 3 to 6, each with semester or quarter, start and end dates, course number and title, credit hours, tuition, allowable fees, total fees and total projected cost for the term.

Certifications

The applicant acknowledges responsibility to notify the scholarship program of changes, and the Dean or Program Director confirms the information is accurate, with name, signature, date, title, phone and email.

How VA Form 10-0491 is completed

  1. 1

    Sign the consent

    The applicant signs and dates the Consent for Release of Information on page 1.

  2. 2

    Fill in the application information

    Mark the program and complete items 1 to 16, from name and institution to expected dates and full-time or part-time attendance.

  3. 3

    Record the CGPA

    The school enters undergraduate and graduate CGPA as the form describes, or checks N/A and indicates good standing where numerical grades are not used.

  4. 4

    List each term's courses and fees

    Use the term tables for courses, credit hours, tuition and fees. The form says all identifiable fees listed are identified as required or optional, and a copy of the program of study or curriculum is part of the package.

  5. 5

    Sign both certifications

    The applicant and the Dean or Program Director each sign and date their certification on page 7.

  6. 6

    Submit through AMS

    The form says the application is considered ineligible if it is not submitted through the Application Management System (AMS) by the specified due date.

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How it is submitted and edition

Application Management System

The form says applicants submit all sections of the application package to the scholarship program office through the Application Management System (AMS) by the due date.

Attachment

The form says a copy of the academic institution's program of study or curriculum is submitted as part of the application package.

Not by email

The burden statement lists [email protected] for comments on the burden estimate and says not to send the completed VA Form 10-0491 to that address.

Edition

The footer reads VA FORM SEP 2026, matching the September 2026 revision date on VA's page. It carries OMB Control No. 2900-0793, which expires 09/30/2029, and an estimated burden of 45 minutes.

Related forms

Who uses VA Form 10-0491?

  • Scholarship applicants

    Applicants mark HPSP, VIOMPSP or HPSP (Vet Center), sign the Consent for Release of Information and the page 7 certification. The form says applicants sign and date all sections within the application package.

  • The Dean or Program Director

    The form says the academic verification is completed by the applicant's Dean/Program Director, Coordinator, or Administrator, who signs page 7 with a title, phone number and email address.

  • The academic institution

    The applicant authorizes the institution to release to VA information on enrollment status and academic standing, including grade point average, plus the plan of study and projected costs.

  • The scholarship program office

    The form says the application package goes to the scholarship program office by the due date through the Application Management System (AMS).

Page 1 says who completes the form and where it goes.

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Questions about Form 10-0491

Who completes VA Form 10-0491?

The form says the academic verification is completed by the applicant's Dean/Program Director, Coordinator, or Administrator of the program of study. The applicant signs the consent and a certification.

How is VA Form 10-0491 submitted?

The form says the application is considered ineligible if it is not submitted through the Application Management System (AMS) by the specified due date.

Which grade point average does the form ask for?

Undergraduate and graduate cumulative grade point average. The form explains when undergraduate CGPA can be left out for graduate students, and that for undergraduate students CGPA is computed on all post-secondary academic courses taken within the past 10 years.

What costs does the form say VA will pay?

The form says VA will pay tuition costs and mandatory/required fees (minus additional scholarships, grants, and/or gifts) for each academic term within the student's agreement period if the college or university includes them on the invoice.

Which fees does the form say VA will not cover?

Its examples include insurance, books and equipment, housing and meal plans, transportation and parking, union and association fees, certification board, testing and licensure fees, transcript and ID fees, and late or penalty fees.

Does the academic program need to be accredited?

Item 9 notes that programs that are not accredited are considered ineligible for the scholarship program, and item 10 asks for the accreditation expiration date.

Can the applicant revoke the consent?

The consent says the authorization is voluntary and may be revoked at any time, and that revoking it after the award may end the award and create liability under 38 U.S.C. §7505 (VIOMPSP) and §7617 (HPSP).