10-0491k

VA Scholarship Offer Response—Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP), Veterans Healing Veterans Medical Access and Education Scholarship Program (VHVMAESP)

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

VA Form 10-0491K: VA Scholarship Offer Response

VA Form 10-0491K is the U.S. Department of Veterans Affairs Scholarship Offer Response. VA's form page names it for the Health Professional Scholarship Program (HPSP), the Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) and the Veterans Healing Veterans Medical Access and Education Scholarship Program (VHVMAESP), and lists it under VHA.

The form says the scholarship award will not be issued until this form is complete and received. The applicant marks whether they accept or decline the scholarship award for an academic year, checks a list of acknowledgments about the scholarship terms and gives bank details for direct deposit of stipends or other related costs.

The PDF is one page. Its accept and decline boxes name the HPSP and VIOMPS scholarship programs; the PDF text does not mention VHVMAESP. 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 10-0491K: VA Scholarship Offer Response, as printed by VA

What's on VA Form 10-0491K

Items 1 to 6: applicant information

Name (Last, First, MI), Social Security number, home address, email address, phone number and a secondary email address.

Item 7: acknowledgments

Check boxes on keeping enrollment and academic standing, following program policies and reporting changes, completing obligated service full-time at a VA facility, the mobility agreement, penalties in the HPSP/VIOMPSP agreement and that the terms were explained.

Acceptance or declination

Accept or decline boxes for the HPSP and the VIOMPS scholarship programs, each with an academic year to fill in.

Payment information

The name of the financial institution, checking or savings account, account number and routing number for direct deposit.

Certification and acknowledgment

Two confirmation boxes, then the printed name, signature and date.

How to fill out VA Form 10-0491K

  1. 1

    Enter your applicant information

    Fill in Items 1 to 6. The form shows formats such as 999-99-9999 for the Social Security number.

  2. 2

    Read and check each acknowledgment

    Item 7 lists the scholarship terms the applicant acknowledges, each with its own check box.

  3. 3

    Accept or decline the award

    Check the appropriate box for the HPSP or VIOMPS scholarship program and fill in the academic years.

  4. 4

    Add direct deposit details

    The form says this information needs to be complete and accurate for direct deposit of stipends or other related costs to be issued, and notes that direct deposits of funds are required.

  5. 5

    Certify, sign and date

    Check both certification boxes, print your name, sign and enter the date as MM/DD/YYYY.

Why fill Form 10-0491k on indox

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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 says the scholarship award will not be issued until this form is complete and received.

Privacy Act notice

VA asks for the information under 38 U.S.C. §7501 (VIOMPSP) and §7611 (HPSP). The form says the information does not have to be provided, but without it VA may be unable to process the request for a scholarship.

Edition

The edition is dated SEP 2026. It carries OMB Control No. 2900-0793, which expires 09/30/2029, with an estimated burden of 15 minutes. The form says not to send the completed form to [email protected].

Related forms

Who uses VA Form 10-0491K?

  • Applicants offered an HPSP award

    One pair of boxes accepts or declines the HPSP Scholarship Program for an academic year the applicant fills in.

  • Applicants offered a VIOMPS award

    A second pair of boxes accepts or declines the VIOMPS Scholarship Program for an academic year.

  • HPSP applicants and clinical rotations

    One acknowledgment is marked applicable for the HPSP Scholarship Program only. It covers attending a required clinical rotation or tour at a location with an affiliation agreement with a VA facility.

  • VA uses the response

    The Privacy Act notice says VA asks for the information to determine eligibility to receive a scholarship award, and that without it VA may be unable to process the request for a scholarship.

The form is completed by the applicant who was offered a VA scholarship.

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Questions about Form 10-0491k

What is VA Form 10-0491K used for?

It is the applicant's response to a VA scholarship offer. The applicant accepts or declines the HPSP or VIOMPS scholarship award for an academic year and gives direct deposit details.

Is the award issued before this form is received?

No. The form says the scholarship award will not be issued until this form is complete and received.

Why does the form ask for bank details?

The form says the payment information is for direct deposit of stipends or other related costs, and notes that direct deposits of funds are required.

What does the form say about relocation?

One acknowledgment says the applicant agreed to the mobility agreement in relocation at their own expense when VA provides an assignment, location or appointment for a residency program or a full-time position.

Does the PDF cover VHVMAESP?

VA's form page names VHVMAESP in the form's title, but the accept and decline boxes in the PDF list only the HPSP and VIOMPS scholarship programs.