Veteran's Application for Compensation and or Pension (21-526), Veteran's Supplemental Claim Application (21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)

Forms and Documents

Document Name	Status
Form VA Form 21-4142 Veteran's Application for Compensation and/ or Pension(21-526), Supplemental Application for Compensation(21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142) Form	Modified
21-4142 Supplemental Stmt (2-25-14).docx Supplementary Document	2014-02-25
21-4142a Supplemental Stmt (2-25-14).docx Supplementary Document	2014-02-25
2900-0001-SuppStmt (2-26-14).docx Supporting Statement A	2014-02-26

IC Document Collections

IC ID	Document Title	Status
28062	Veteran's Application for Compensation and/ or Pension(21-526), Supplemental Application for Compensation(21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142) Form	Modified

ICR Details

OMB Control No: 2900-0001	ICR Reference No: 201312-2900-025
Status: Historical Inactive	Previous ICR Reference No: 201204-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0001 VBA-COMP-NK
Title: Veteran's Application for Compensation and or Pension (21-526), Veteran's Supplemental Claim Application (21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 03/12/2014
	Date Received in OIRA: 02/28/2014
Terms of Clearance: Terms of the previous clearance remain in effect. VA has requested withdrawal of this information collection request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved	03/31/2016
Responses	595,000	0	595,000
Time Burden (Hours)	441,982	0	441,982
Cost Burden (Dollars)	0	0	0

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Abstract: VA Forms 21-526 and 21-526b are used to gather the necessary information to determine a veteran's eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible. VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA. This information collection is associated with the AO81 Rule.

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Authorizing Statute(s): US Code: 38 USC Section 5101(a) Name of Law: Claims and forms
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO81	Proposed rulemaking	78 FR 211	10/31/2013

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 2	01/03/2014
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Veteran's Application for Compensation and/ or Pension(21-526), Supplemental Application for Compensation(21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)	VA Form 21-4142, VA Form 21-526, VA Form 21-526b, VA Form 21-4142a	Authorization to Disclose Information to the Department of Veterans Affairs (VA) ,   Veterans Application for Compensation and/or Pension ,   Supplemental Application for Compensation ,   General Release for Medical Provider Information To the Department of Veterans Affairs (VA)

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Burden increased because we added a new form. VA has newly created the VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). The new VA Form 21-4142a is created to gather PHP information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.

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Annual Cost to Federal Government: $12,700,356

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 02/28/2014

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