Notice of Disagreement (VA Form 21-0958)

ICR 201401-2900-003

OMB: 2900-0791

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2014-08-21
IC Document Collections
IC ID
Document
Title
Status
202598 Modified
ICR Details
2900-0791 201401-2900-003
Historical Active 201206-2900-001
VA 2900-0791 VBA-COMP-NK
Notice of Disagreement (VA Form 21-0958)
Revision of a currently approved collection   No
Regular
Approved with change 09/30/2014
Retrieve Notice of Action (NOA) 07/30/2014
  Inventory as of this Action Requested Previously Approved
03/31/2016 36 Months From Approved 03/31/2016
144,000 0 144,000
72,000 0 72,000
0 0 0

This form is used to initiate disagreement with VA regarding a decision on a claim in order to file an appeal. VA Form 21-0958, this form is associated with the AO81 rule.

US Code: 38 USC 1521(d) and (e) Name of Law: Veterans of a period of war
   US Code: 38 USC 1114 Name of Law: Rates of wartime disability compensation
   US Code: 38 USC 1151(1)(E) Name of Law: Benefits for persons disabled by treatment or vocational rehabilitation
   US Code: 38 USC 1311(d) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1541(d) and (e) Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 7105(a) Name of Law: Filing notice of disagreement and appeal
  
None

2900-AO81 Final or interim final rulemaking 78 FR 211 10/31/2013

No

1
IC Title Form No. Form Name
Notice of Disagreement (21-0958) VA Form 21-0958 Notice of Disagreement

  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 144,000 144,000 0 0 0 0
Annual Time Burden (Hours) 72,000 72,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$7,229,520
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.
07/30/2014


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