2900-0114 justification

Supporting Statement for VA Form 21-4170

Statement of Marital Relationship

(2900-0114)

A. Justification

1. The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. Certain veterans who are entitled to VA compensation and/or pension benefits may be entitled to an additional allowance for a spouse, and surviving spouses of deceased veterans may be entitled to VA death benefits. A valid marriage must be established. Information is requested by this form under the authority of 38 U.S.C. 101(3), 38 U.S.C. 101(31), and 38 U.S.C. 103(c) which provide that a marriage is valid for VA purposes if it is valid under the law of the place where the parties resided at the time of the marriage, provided the marriage is between persons of the opposite sex. A number of states recognize common law marriages.

2. VA Form 21-4170 is used to gather information that is necessary to determine whether a valid common law marriage was established. The form is used by persons claiming to be common law widows/widowers of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established.

3. VA Form 21-4170 is available on the One-VA Website in a fillable electronic format. VBA is currently hosting these forms on a secure server and does not currently have the technology in place to allow for the complete submission of the forms. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the forms to be incorporated with an existing centralized legacy database. Veterans Online Applications (VONAPP) allows applicants to view, print, and submit applications electronically to VBA. However, VA Form 21-4170 is not one of the forms scheduled to be added to VONAPP because estimated total usage of this form is low. The Department will reconsider adding this form to VONAPP when the resources become available or if usage of this form becomes greater.

4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.

5. The collection of information does not involve small businesses or entities.

6. The VA compensation and pension programs require current information to determine eligibility for benefits. Without the information provided on this form, VA would be unable to determine whether claimants had established a common law marriage and authorize benefits.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in the Federal Register on October 1, 2007, page 55861. No comments were received.

9. No payments or gifts to respondents have been made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22, "Compensation, Pension, Education and Rehabilitation Records - VA" as set forth in Privacy Act Issuances, 1993 compilation found in 42 Fed. Reg. 49726 (9/27//1977).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 6,500 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 2,708 hours.

d. The estimated completion time of 25 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $40,620 (2,708 hours x $15 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $99,125

(GS-9/5 @ $25.00 x 6,500 x 30/60 minutes = $81,250)

(GS-3/5 @ $16.50 x 6,500 x 10/60 minutes = $17,875)

b. Printing and production cost ($25/thousand) $175

c. Total cost to government $99,300

15. There is no change in the respondent burden.

16. The information collection is not for publication or tabulation use.

17. The collection instrument, VA Form 21-4170, may be reproduced and/or stocked by the respondents and veterans service organizations. This VA form does not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of this form. This form is submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action on the benefit being sought. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA continues to seek an exemption that waives the displaying of the expiration date on VA Form 21-4170.

18. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

The Veterans Benefits Administration does not collect information employing statistical methods.