2900-0114SupportState

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.

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 January 3, 2014, page 427, Vol. 79, No. 2. 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 58VA21/22/28,‘‘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 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. 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 $64,992. (2,708 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 $107,087

(GS-9/5 @ $28.04 x 6,500 x 30/60 minutes = $91,130)

(GS-3/5 @ $14.73 x 6,500 x 10/60 minutes = $15,957)

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

c. Total cost to government $107,262

15. There is no change in the respondent burden. The form has been updated to include the

expiration date placeholder.

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.