Exemption Checksheet
Former Scholar:___________________ Grant Number:_____________________
College or University: ________________________ RSA Staffer:_____________________
Reason of Exemption (check one) ‑‑
Is unable to continue the course of study or perform the work obligation because of a disability that is expected to continue indefinitely or result in death; or
Documentation needed:
( ) A Signed statement by a qualified, licensend physicians stating that:
( ) the disability is permanent and
( ) the former scholar is unable to continue the course of study or perform the work obligation.
( ) Documentation must include diagnosis and prognosis.
Has died.
Documentation needed:
( ) a death certificate or other evidence conclusive under State law.
Final Action
___ Approved (date and Division Director’s initials)_________________
____ Disapproved (date and Division Director’s initials)_________________
Rehabilitation Services Administration
Name Address
Dear :
You have requested an exemption from your “payback” obligations under the terms of your Rehabilitation Services Administration (RSA) scholarship agreement. In order to consider your request, we need certain information, as indicated in the enclosed form.
Please compete the form and return to the address below within the next two weeks.
Ms. Joan Dickie
Rehabilitation Services Administration
Room 3321 Switzer Building
330 C Street, SW
Washington, DC 20202-2649
If you have any questions regarding the payback of this scholarship, please call Ms. Joan Dickie. Ms. Dickie can be reached at 202-205-8871.
Thank you for your cooperation in this matter.
Sincerely,
Timothy C. Muzzio, Ph.D.
Director
Division of Resource Development
cc: Payback file
Rehabilitation Services Administration
RSA Scholarship Deferral Request Form
Former Scholar Information
Name: Phone Number:
Address: Social Security No.:
Former or Maiden Names used:
University attended under RSA scholarship:
Department:
Instructor through which the scholarship was arranged:
Dates of attendance as a scholarship recipient:
Did you complete the degree program (yes/no):
Below are listed the allowable reasons for exemptions. Please check the appropriate box, and submit the documentation required:
Former scholar is unable to continue the course of study or perform the work obligation because of a disability that is expected to continue indefinitely or result in death.
Documentation needed: A Signed statement by a qualified, licensed physicians stating that:
1. the disability is permanent and
2. the former scholar is unable to continue the course of study or perform the work
obligation.
3. documentation must include diagnosis and prognosis.
Former scholar has died.
Documentation needed: a death certificate or other evidence conclusive under State law.