2900-0001-SuppStmt (2-26-14)

Supporting Statement for:

Veteran’s Application for Compensation and/or Pension, VA Form 21-526, Veteran’s Supplemental claim Application, VA Form 21-526b, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), VA Form 21-4142a, and Authorization and Consent to Release Information to the Department of Veterans Affairs, VA Form 21-4142

(2900-0001)

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. Title 38 U.S.C. 5101(a) provides that a specific claim in the form provided by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by the Secretary. VA Form 21-526 is the prescribed form for initial disability claims. VA Form 21-526b is the prescribed form for supplemental disability or ancillary benefit claims. VA Form 21-4142 is used to authorize the disclosure of information to the Department of Veterans Affairs (VA) and VA Form 21-4142a is used to gather private provider information of the Veteran to VA.

These forms information collections are associated with the AO81 rule.

2. VA Form 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 has updated the direct deposit information on the VA Form 21-526 to comply with Department of Treasury requirements.

VA added a field to the 21-526 requesting information on a claimant’s transferred assets based on the following VA Office of General Counsel opinion:

• “We have seen a lot of activity from attorneys practicing elder law, who, in some cases, claim that they can assist individuals in qualifying for VA aid and attendance by transferring their assets using various types of trust instruments.  As you probably know, VA must generally consider such assets in determining eligibility unless the applicant relinquished all ownership and control.  We have communicated with a few individuals regarding their promotional material, which implies that prior to applying for pension the claimant may transfer assets and that there is no need to inform VA of the transfer.  This presents a problem because attorneys may advise claimants to transfer their assets, charge a fee for the transfer, and assist the claimant in preparing a pension claim.  A few years later, when VA learns of the transferred assets, which the claimant continued to control, VA creates a debt that the beneficiary may not be able to repay.  Family members then request a waiver.  This has actually happened in a few cases.

• I note that the 21-526 form does not inquire about transfers of assets prior to the date of application.  This may be something that VBA should add to the form.  Attorneys’ ethical obligation to advise claimants about asset transfers would then be clear.”

Additionally, claimants who need assistance in obtaining non-VA medical records complete VA Form 21-4142. VA is revising the VA Form 21-4142 to be compliant with Health and Human Services and Social Security Administration forms. Instead of requiring a signed form from the claimant for each private health provider (PHP), the claimant only has to give VA this general consent to go out for these records. The consent was also increased from six months to one year.

However, in the redesign of the VA Form 21-4142, the PHP information is not gathered anywhere else in the application process thus increasing the burden on VA to develop for this information. 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.

3. VA Form (21-4142, 21-4142a, 21-526, and 21-526b) 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. These forms were redesigned into a “user friendly” form, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing.

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, Vol. 79, No. 2, pages 424 and 425. 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 “Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 (June 19, 2009).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

1. Number of yearly respondents is estimated at:

   1. 391,708 for VAF 21-526,

   2. 66,200 for VAF 21-4142,

   3. 66,200 for VAF 21-4142a, and

   4. 200,000 for VAF 21-526b.

2. Frequency of Response is one time for most beneficiaries.

3. Annual burden total is 452,740:

   1. 391,708 for VAF 21-526,

   2. 5,516 for 21-4142,

   3. 5,516 for 21-4142a, and

   4. 50,000 for VAF 21-2526b.

4. The estimated completion time is:

   1. 60 minutes for VA Form 21-526,

   2. 15 minutes for VA Form 21-526b,

   3. 5 minutes for 21-4142, and

   4. 5 minutes for 21-4142a.

5. The total estimated cost to respondents is $10,865,760 (452,740 x $24 per hour).

13. Supplemental Statement for VA Form 21-4142:

VA is redesigning the current VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), Feb 2012. VA is revising the VA Form 21-4142 to be compliant with Health and Human Services and Social Security Administration forms. Instead of requiring a signed form from the claimant for each private health provider (PHP), the claimant only has to give VA this general consent to go out for these records. The consent was also increased from six months to one year.

VA is also redesigning the form for clarity and ease of use. This redesign does not increase the respondent burden.

Supplemental Statement for VA Form 21-4142a:

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.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $12,694,866

• (GS- 9/5 @ $28.04 x 391,708 x 60/60 minutes = $10,983,492)

• (GS- 9/5 @ $28.04 x 200,000 x 15/60 minutes = $1,402,000)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

b. Forms are available on the VA inter/intranet forms websites.

c. Printing and production cost ($90/thousand) $5,490

d. Total cost to government $12,700,356

15. The increase in burden is due to the Notice of Proposed Rulemaking (NPRM) RIN 2900-AO81, “Standard Claims and Appeals Forms” which proposes to require all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA is proposing to codify its regulations to standardize the use of all VA forms, to include VA Forms 21-526 and 21-526b. Currently, other than for the initial original claim, VA does not require that claimants submit any subsequent claim on a prescribed VA form. Although there is no substantive change in these forms, VA expects a change in the number of respondents submitting VA Forms 21-526 and 21-526b on account of VA’s electronic claims processing system which uses another form, i.e., VA Form 21-526EZ, that contains the 38 U.S.C. 5103 notices to claimants and that essentially combines the existing VA Form 21-526 and VA Form 21-526b together. The total estimated costs to respondents and the federal government have changed as shown in paragraphs 12 and 14 of this statement.

We are not seeking approval to omit the expiration date for OMB approval.

16. The change of the direct deposit information has no effect on the respondent burden as this information was already a part of the form and it has been changed to comply with the Department of Treasury requirement.

VA is revising the VA Form 21-4142 to be compliant with Health and Human Services and Social Security Administration forms. This change will not add to the respondent burden.

17. The information collection is not for publication or tabulation use.

18. We are not seeking approval to omit the expiration date for OMB approval.

19. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

The data collection does not employ statistical methods.