10-0491i

Notice of Change and/or Annual Academic Status—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Agency
VA
Revision
September 2026
Fillable fields
60
Pages
2
Official source
VA form page
Checked
October 20, 2026
Fill 10-0491i online
Page 1 of form 10-0491i

VA Form 10-0491I: Notice of Change and/or Annual Academic Status

VA Form 10-0491I is the U.S. Department of Veterans Affairs Notice of Change and/or Annual Academic Status for the Health Professional Scholarship Program (HPSP) and the Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP). VA's form page lists it under VHA.

The form says the purpose of completing a notice of change is to maintain good standing in the HPSP Scholarship Program, and that HPSP recipients complete it at a minimum monthly along with monthly check-ins while enrolled in the program of study or during academic breaks. The recipient marks one of three options: no change and good academic standing, a minor change or a major change.

The PDF is two pages. Page 1 holds the instructions, the Privacy Act notice and the first change items. Page 2 holds the remaining changes, the participant's comments and signature, and the advisor's comments and signature. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 10-0491I: Notice of Change and/or Annual Academic Status, as printed by VA

What's on VA Form 10-0491I

Header and type of change

The participant's name (Last, First, Middle), the SSN (last 4 only), the program box and the choice of no change, minor change or major change.

Contact and course cost changes

Name, address and email address changes, each with From and To, a projected course cost change and a repeat course with its title, course number and the term to retake it.

Academic status changes

A change in graduation date, academic probation with a remedial course of action and expected date, voluntary withdrawal from courses and a change from full-time to less than full-time.

Withdrawal, leave and suspension

Voluntary withdrawal from or dismissal by the program of study or academic institution, a leave of absence and a request for suspension, each with dates and a documentation note.

School change and USMLE dates

A school change with the new school's anticipated start date and, only for HPSP physician recipients, the dates USMLE Step 1 and Step 2 were passed.

Comments and signatures

Participant comments and signature, then advisor comments and signature.

How to fill out VA Form 10-0491I

  1. 1

    Read the page 1 instructions

    They explain no change, minor change and major change, and say items with an asterisk require proof of documentation.

  2. 2

    Enter your name and program

    Fill in the name and the last 4 digits of the SSN, mark the program box and pick the type of change.

  3. 3

    Fill in the changes that apply

    Enter the From and To details for each change marked. The form asks for dates as MM/DD/YYYY.

  4. 4

    Gather any documentation

    The notes on the form say which changes require proof of documentation, academic advisor concurrence or HPSP Program Office concurrence.

  5. 5

    Sign it and add the advisor section

    Add any participant comments and sign. Page 2 then has space for the advisor's comments and signature.

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Sending it and other notes

Where it goes

The form does not print a mailing address, fax number or upload site. It refers to the HPSP Scholarship Program and the HPSP Program Office for questions about a recipient's status.

Address changes for payments

The form says that for physical address changes, the recipient is responsible for updating their information in the VA Customer Engagement Portal (CEP) where direct deposits/EFT occur.

Privacy Act notice

VA asks for the information under 38 U.S.C. §7501 (VIOMPSP) and §7611 (HPSP) to administer the scholarship award. The form says that without it, VA may be unable to continue the scholarship award.

Edition

The edition is dated SEP 2026. It carries OMB Control No. 2900-0793, which expires 09/30/2029, with an estimated burden of 20 minutes. The form says not to send the completed form to [email protected].

Related forms

Who uses VA Form 10-0491I?

  • Scholarship participants

    The participant enters a name and the last 4 digits of the SSN, then marks the program box the form prints as HPSP, VIOMSP or Vet Center.

  • Recipients with no changes

    The form says a recipient who marks no changes is attesting that no changes are made and that they remain in good academic standing.

  • Recipients with a minor change

    The form says a minor change is a change of name, address, contact information or email address.

  • Recipients with a major change

    The form says the requirements and proof of documentation depend on the change, and that some changes may need a meeting with the HPSP Program Office.

  • Academic advisors

    Page 2 has space for advisor comments and an advisor signature. Some items, such as a change in graduation date, note academic advisor review and concurrence.

The form describes who completes each part.

Official sources and the blank

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Questions about Form 10-0491i

Who completes VA Form 10-0491I?

The scholarship participant fills in the form and signs it. Page 2 also has space for an advisor's comments and signature.

How often is the notice of change completed?

The form says HPSP recipients complete it at a minimum monthly, along with monthly check-ins, while enrolled in the program of study or during academic breaks covered by the scholarship.

What counts as a minor change?

The form lists a change of name, address, contact information or email address. For a physical address change it also points to the VA Customer Engagement Portal (CEP), where direct deposits are handled.

How long can a suspension last?

The form says suspensions are valid for up to one (1) year and available to use two (2) times during a recipient's time in the HPSP Scholarship Program. A request for suspension requires proof of documentation.

What happens to stipends during a leave of absence?

The form says all monthly stipends and annual book stipends are temporarily paused while the recipient is not enrolled or active in the program of study.

Does a school change need approval first?

The form says pre-authorization by the HPSP Program Manager or designee is required before the transfer, and that without it the recipient's status changes to breach and a bill of collection is issued.

Does the program pay for a repeated course?

The repeat course row carries the note: HPSP Program does not cover or reimburse.