10-0491c

Annual VA Employment or Deferment Verification—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Agency
VA
Revision
September 2026
Fillable fields
35
Pages
1
Official source
VA form page
Checked
October 20, 2026
Fill 10-0491c online
Page 1 of form 10-0491c

VA Form 10-0491C: Annual VA Employment or Deferment Verification

VA Form 10-0491C is the U.S. Department of Veterans Affairs Annual VA Employment or Deferment 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. A scholarship participant marks whether it is submitted for annual employment verification or annual deferment verification, and a supervisor or advisor signs it with the participant.

The form is one page. The top holds the burden statement and Privacy Act notice, then the participant's name, Social Security number, address, phone, email, clinical program while in school and date degree conferred. The left column covers employment during the service obligation at a VA facility, the right column covers a Post Graduate Year (PGY) residency, and the bottom holds the HPSP/VIOMPSP address and the signature lines. It is a form for scholarship participants and their supervisors, not a Veterans benefit application.

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Top of page 1 of VA Form 10-0491C: Annual VA Employment or Deferment Verification, as printed by VA

What's on VA Form 10-0491C

Notices

The burden statement for OMB Control No. 2900-0793 and the Privacy Act notice citing 38 U.S.C. §7502 (VIOMPSP) and §7611 (HPSP).

Participant details

HPSP or VIOMPSP checkbox, name, Social Security number, address, phone, email, clinical program while in school and date degree conferred.

Annual employment verification

Service obligation start date, position title, grade and step, VA facility name and address, and statements on full-time employment, no leave without pay, no anticipated changes and a satisfactory performance evaluation.

Annual deferment verification

PGY residency dates, years and program details, and statements on continuing in the residency, a satisfactory evaluation, no anticipated changes and a State Medical License with state and license number.

Address and signatures

The HPSP/VIOMPSP address, the scholarship participant's signature and date, and the supervisor or advisor's signature, date, title or position and phone.

How VA Form 10-0491C is completed

  1. 1

    Fill in your details

    Mark HPSP or VIOMPSP and enter your name, Social Security number, address, phone, email, clinical program and date degree conferred.

  2. 2

    Choose employment or deferment

    Mark Submitted for Annual Employment Verification or Submitted for Annual Deferment Verification, then complete that column.

  3. 3

    Check the statements that apply

    The form says to check all applicable blocks, and to explain any that are not applicable in the comments section.

  4. 4

    Attach the SF-50 for employment

    For employment verification, the form says to attach a copy of your most recent Notification of Personnel Action (SF-50).

  5. 5

    Sign with your supervisor or advisor

    Sign and date as the scholarship participant, and have the supervisor or advisor sign, date and add a title and phone number.

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Where it goes and edition

Address on the form

HPSP/VIOMPSP: Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113.

Residency ending within 90 days

The deferment column says to submit "Education Program Completion Notice/Service Obligation Placement" if the post graduate residency will be completed within 90 days.

Not by email

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

Related forms

Who uses VA Form 10-0491C?

  • Participants serving a service obligation

    For annual employment verification, the form asks for the service obligation start date, current position title, grade and step, and the VA facility, with a copy of the most recent Notification of Personnel Action (SF-50) attached.

  • Participants in a residency deferment

    For annual deferment verification, the form asks for the PGY residency start date, the anticipated date to begin the service obligation, the PGY completed, total years in the program and the program's name and address.

  • The supervisor or advisor

    Signs and dates the form below the participant and adds a title or position and a phone number.

  • The Scholarship Program Office

    The checkbox statements say the participant will notify the Scholarship Program Office as soon as they become aware of anticipated changes.

The form names the participant, the supervisor or advisor and the program office.

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Questions about Form 10-0491c

What is VA Form 10-0491C?

It is the Annual VA Employment or Deferment Verification for HPSP and VIOMPSP scholarship participants, a one page VHA form covering either VA employment during the service obligation or a PGY residency deferment.

Who signs VA Form 10-0491C?

The scholarship participant and a supervisor or advisor, who also gives a title or position and a phone number.

What is attached for employment verification?

The form says to attach a copy of your most recent Notification of Personnel Action (SF-50) to the report.

What if my residency ends within 90 days?

The form says to submit "Education Program Completion Notice/Service Obligation Placement" if the post graduate residency will be completed within 90 days.

What if a statement does not apply to me?

The form says to check all applicable blocks and, if any of the blocks are not applicable, to explain in the comments section.

What address is printed on the form?

HPSP/VIOMPSP: Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113.