Supporting Statement for VA Form 21P-4171
Supporting Statement Regarding Marriage
(2900-0115)
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. Information is requested by this form under the authority of 38 U.S.C. 103 which requires that a marital relationship be established before benefits may be paid to or for a spouse of a veteran.
VA Form 21P-4171, Supporting Statement Regarding Marriage, has been transferred from Compensation Service to Pension and Fiduciary Service, due to changes in business lines. The expiration date is also being added to the form.
2. VA Form 21P-4171 is used to gather the necessary information from individuals who know, as the result of personal observation, the relationship which existed between the veteran and claimed spouse, when common law marriage is claimed. This information is necessary to determine if a marital relationship is established and benefits are payable based on the marital relationship.
3. VA Form 21P-4171 is available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. 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 form to be incorporated with an existing centralized legacy database.
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. VA Form 21P-4171 requests information needed to determine eligibility to benefits based on marital relationship. Without this information, an accurate determination of a common law marital relationship would not be made, and benefits would not be properly paid.
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 January 15, 2014, Volumne 79, No. 10, Page 2755. No comments were received in response to this notice.
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 58VA21/22/28,‘‘Compensation, Pension, Education, and Rehabilitation Records—VA ’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
11. There are no questions of a sensitive nature.
12. Estimate of Information Collection Burden.
a. Number of Respondents is estimated at 2,400 per year.
b. Frequency of Response is one time for most respondents.
c. Annual burden is 800 hours.
d. The estimated completion time of 20 minutes is based on review by staff personnel and previous usage of this form.
e. According to the U.S. Bureau of Labor Statistics Average Hourly Earnings, the cost to the respondent is $24, making the total cost to the respondents an estimated $19,200. (800 hours x $24 per hour).
13. This submission does not involve any recordkeeping costs.
14. Estimated Costs to the Federal Government:
a. Processing/Analyzing costs $54,007
(GS-9/5 @ $28.04 x 2,400 x 45/60 minutes = $50,472)
(GS-3/5 @ $14.73 x 2,400 x 6/60 minutes = $ 3,535)
b. Printing and production cost $160
c. Total cost to government $54,167
15. There is no change in the reporting burden. The expiration date is being added to the form along with updating the prefix number.
16. The information collection is not for publication or tabulation use.
17. We are not seeking approval to omit the expiration date for OMB approval.
18. This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
This collection of information does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SF 83 SS VAF 21-8926 |
| Author | Veterans Benefits Administrat |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |