Supplemental Income Questionnaire (For Philippine Claims Only) (21P-0784)

ICR 201312-2900-012

OMB: 2900-0668

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
2900-0668 201312-2900-012
Historical Active 201103-2900-011
VA 2900-0668 VBA-P&P-NK
Supplemental Income Questionnaire (For Philippine Claims Only) (21P-0784)
Revision of a currently approved collection   No
Regular
Approved without change 11/19/2014
Retrieve Notice of Action (NOA) 08/29/2014
  Inventory as of this Action Requested Previously Approved
11/30/2017 36 Months From Approved 11/30/2014
120 0 120
30 0 30
0 0 0

VA Form 21P-0784 is used to gather income information that is necessary to determine a claimant's entitlement to pension benefits. It is used only by Philippine claimants who reside in the Philippines. Without information about a claimant's family income and net worth, VA would not be able to properly determine entitlement to pension and the rate payable.

US Code: 38 USC 107 Name of Law: Certain service deemed not to be active service
   US Code: 38 USC 1521 Name of Law: Veterans of a period of war
   US Code: 38 USC 1541 Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 1542 Name of Law: Children of veterans of a period of war
   US Code: 38 USC 1506 Name of Law: Resource reports and overpayment adjustments
  
None

Not associated with rulemaking

  79 FR 11 01/16/2014
79 FR 163 08/22/2014
No

1
IC Title Form No. Form Name
Supplemental Income Questionnaire (For Philippine Claims Only) (21P-0784) VA Form 21P-0784 Supplemental Income Questionnaire (Phillipine Claims Only)

  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 120 120 0 0 0 0
Annual Time Burden (Hours) 30 30 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$3,627
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 crystal.rennie@va.gov

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/29/2014


© 2024 OMB.report | Privacy Policy