10-0491L
VA Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) Agreement
VA Form 10-0491L is the U.S. Department of Veterans Affairs Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) Agreement. VA's form page lists it under VHA. The form says its purpose is to outline the roles and responsibilities of the VIOMPSP Scholarship Program and the VIOMPSP scholarship recipient, and that it is the responsibility of the recipient to read through each section and make sure they understand their obligation before signing.
The PDF is three pages. Sections A to F cover the program, the obligations of the Under Secretary for Health (USH), the obligations of the recipient, breach of the agreement, cancellation, suspension and waiver of obligation, and consent for release of information. Section G holds the general provisions, three statements to initial and signature lines for the applicant and for the USH or an authorized representative.
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Section A cites 38 United States Code, Sections §7501-§7505. Section B covers the award of tuition and required fees and appointment to a full-time direct patient care position within 90 days after the recipient completes the education and meets VA qualification requirements.
Accepting the award, keeping enrollment and academic standing, reporting changes through the Notice of Change Form, sharing transcripts, signing a mobility agreement and serving a period of obligated service validated by an SF-50.
Eight situations that count as a breach, such as dismissal or withdrawal from the program of study, with the liquidated damages and the recovery formula A = 3P((t-s)/t).
Cancellation on the death of the participant, when the USH may waive or suspend an obligation, the time limit for waiver requests and that waiver decisions are final.
Consent for the academic institution to report status and academic standing, which the form says is voluntary and can be revoked at any time.
A blank for the period of obligated service, three statements to initial, the applicant's printed name, signature and date, and the USH or authorized representative's signature and date.
The form says it is the recipient's responsibility to read through each section and make sure they understand their obligation before signing.
Section G's instructions say to review, check, sign initials, print first and last name and sign.
Each statement in Section G, including the one stating the period of obligated service, has its own Initial Here line.
Fill in the applicant's printed name, signature and the date as MM/DD/YYYY.
The agreement becomes effective once the Under Secretary for Health or an authorized representative accepts it, using the second signature line.
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The form does not print a mailing address, fax number or upload site.
Section B states a maximum of $15,000 per academic year and VHA fiscal year (October 1 to September 30) for full-time students, and a total that may not exceed $45,000.00. Section D lists the sum of $1,500 as liquidated damages in several breach situations.
The edition is dated MAY 2026. The PDF text does not print an OMB control number.
10-0491f
13 fields, 4 pages
10-0491k
35 fields, 1 page
10-0491i
60 fields, 2 pages
10-0491
481 fields, 7 pages
10-0491c
35 fields, 1 page
10-0491j
24 fields, 1 page
The agreement names the parties and what each one signs or agrees to.
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It is the VIOMPSP Agreement. The form says it outlines the roles and responsibilities of the VIOMPSP Scholarship Program and the scholarship recipient.
Section B says the award consists of payment of tuition and required fees as determined by the USH, with a maximum of $15,000 per academic year and VHA fiscal year for full-time students and prorated amounts for part-time students. It says the total may not exceed $45,000.00.
Section C says service obligation periods are set for a three-year period at a minimum and completed no later than six (6) years after the participant completes the program of study or degree.
Section D lists eight breach situations. In several of them the form says the participant pays the United States the sum of $1,500 as liquidated damages, within one year of the date the breach is found.
Section E says the USH may waive or suspend it if compliance is impossible due to circumstances beyond the participant's control, or when considered in the best interest of VA. Waiver requests go to the USH within one year, and waiver decisions are final.
The applicant initials Section G and signs it. The Under Secretary for Health or an authorized representative also signs, and the form says the agreement is not effective until they accept it.
