Supporting Statement Regarding Marriage

Forms and Documents

Document Name	Status
Form VA Form 21-4171 Supporting Statement Regarding Marriage Form	Modified
2900-0115 justification.doc Supporting Statement A	2008-04-03

IC Document Collections

IC ID	Document Title	Status
28317	Supporting Statement Regarding Marriage Form	Modified

ICR Details

OMB Control No: 2900-0115	ICR Reference No: 200712-2900-015
Status: Historical Active	Previous ICR Reference No: 200506-2900-004
Agency/Subagency: VA	Agency Tracking No: 2900-0115
Title: Supporting Statement Regarding Marriage
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/12/2008
	Date Received in OIRA: 04/03/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2011	36 Months From Approved	08/31/2008
Responses	2,400	0	2,400
Time Burden (Hours)	800	0	800
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Form 21-4171 is used to gather information that is needed to determine eligibility to benefits based on a common law marital relationship. The information is gathered from persons who can attest to the nature of the relationship that existed between the veteran and claimed spouse. Without this collection of information, VA would be unable to accurately determine whether a common law marriage existed, and benefits would not be properly paid.

---

Authorizing Statute(s): US Code: 38 USC 103 Name of Law: Special provisions relating to marriages
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 14	01/22/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 63	04/01/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Supporting Statement Regarding Marriage	VA Form 21-4171	Supporting Statement Regarding Marriage

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,400	2,400	0	0	0	0
Annual Time Burden (Hours)	800	800	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $48,314

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/03/2008

---