Statement in Support of Claim (21-4138)

ICR 201404-2900-014

OMB: 2900-0075

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2014-10-16
Supplementary Document
2014-09-16
Supporting Statement A
2014-09-16
IC Document Collections
IC ID
Document
Title
Status
28224 Modified
ICR Details
2900-0075 201404-2900-014
Historical Active 201104-2900-024
VA 2900-0075 VBA-COMP-DB
Statement in Support of Claim (21-4138)
Revision of a currently approved collection   No
Regular
Approved without change 01/16/2015
Retrieve Notice of Action (NOA) 10/29/2014
  Inventory as of this Action Requested Previously Approved
01/31/2018 36 Months From Approved 01/31/2015
752,000 0 752,000
188,000 0 188,000
0 0 0

VA Form 21-4138 is used to provide self-certified statements in support of various types of claims processed by VA. Statements submitted by or on behalf of a claimant should contain certification by the respondent that the information provided is true and correct. This form facilitates claims processing by providing a uniform format for the certification statement.

US Code: 38 USC 501 Name of Law: Rules and regulations
  
None

Not associated with rulemaking

  79 FR 137 07/17/2014
79 FR 189 09/30/2014
No

1
IC Title Form No. Form Name
Statement in Support of Claim (21-4138) 21-4138 Statement in Support of Claim

  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 752,000 752,000 0 0 0 0
Annual Time Burden (Hours) 188,000 188,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$27,662,069
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.
10/29/2014


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