10-0491d
Education Program Completion Notice/Service Obligation Placement—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
VA Form 10-0491D is the Department of Veterans Affairs Education Program Completion Notice/Service Obligation Placement for the Health Professional Scholarship Program (HPSP) and the Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP). It is completed by a scholarship recipient, not by Veterans applying for benefits. VA's page lists it under the Veterans Health Administration (VHA).
The form says its purpose is to ensure the HPSP recipient has successfully completed all requirements in their program of study and met VA qualification standards before the service obligation period in the HPSP agreement begins, to monitor the recipient for completion of the obligated service, and to ensure the recipient has a location and assignment to begin employment and obligated service.
It is one page: a description of the obligated service, the Privacy Act and burden notices, application information, the required documents, an annual attestation, and a certification with the recipient's name, signature and date. You can fill out the PDF free in your browser on this page and download the result without an account.
The form describes the obligated service as the period during which the recipient is employed by VA in a full-time clinical occupation for which the degree prepared them. It becomes effective once the recipient meets VA qualification standards, which may include licensure or credentialing and privileging.
The form says failing to begin or complete the service obligation puts the recipient in breach, liable to repay all scholarship funds paid to them and to the school on their behalf, plus interest, multiplied by three, minus months of service obligation satisfied.
A checkbox for HPSP, VIOMSP or HPSP (Vet Center), then name, home address, phone number and Social Security number. The form notes that home address changes are updated in the VA-CEP portal.
Two checkboxes for documents included when submitting the form: a copy of the final job offer and a copy of the SF-50 Notification of Personnel form.
Checkboxes for a copy of the most recent SF-50 and the most recent performance appraisal or evaluation, uploaded each year as the annual check-in.
Three statements about fulfilling the obligatory service in the HPSP agreement, the accuracy of the information and the effect of a breach, then name, signature and date (MM/DD/YYYY).
Mark HPSP, VIOMSP or HPSP (Vet Center) in the application information box.
Fill in your name (last, first, middle), home address, phone number and Social Security number in the formats the form prints.
Get a copy of the final job offer and a copy of the SF-50 to include with the form.
Check the three certification and acknowledgement statements, then print your name, sign and enter the date.
The form says the required documents are included when submitting the form and uploading into the Application Management System (AMS) system of record.
For the annual check-in, the form says the recipient uploads a copy of the most recent SF-50 and performance appraisal or evaluation into AMS.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form names the Application Management System (AMS) system of record as where the form and its required documents are uploaded. It prints no mailing address.
The form says changes to the home address require the recipient to update their information in the VA-CEP portal.
The burden statement says not to send the completed VA Form 10-0491d to [email protected], the address for comments on the burden estimate.
The PDF footer reads VA FORM SEP 2026 10-0491d, 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 15 minutes.
10-0491f
13 fields, 4 pages
10-0491h
18 fields, 1 page
10-0491c
35 fields, 1 page
10-0491j
24 fields, 1 page
10-0491i
60 fields, 2 pages
10-0491g
118 fields, 7 pages
The form is for scholarship recipients moving from school to their VA service obligation.
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It is the Education Program Completion Notice/Service Obligation Placement for HPSP and VIOMPSP scholarship recipients, used before the service obligation period in the HPSP agreement begins.
A scholarship recipient in HPSP, HPSP (Vet Center) or VIOMPSP. It is not a form for Veterans applying for benefits.
The form lists a copy of the final job offer and a copy of the SF-50 Notification of Personnel form, uploaded with it into the Application Management System (AMS).
The form says that at a minimum the recipient uploads a copy of the most recent SF-50 and performance appraisal or evaluation into AMS each year.
The form says recipients under the HPSP Vet Center Scholarship have an obligation period of service of six (6) years, including licensed supervised hours leading up to licensure, certification or registration.
It says a recipient who does not begin or complete the service obligation is liable to repay all scholarship funds paid, plus interest, multiplied by three, minus months of service satisfied, within 1 year of the failure as determined by the Secretary.
