2900-0094SuppStmt

Supporting Statement for VA Form 21-4169

Supplement to VA Forms 21-526, 21P-534, and 21P-535 (For Philippine Claims)

(2900-0094)

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. Eligibility to benefits may be established based on service in the Commonwealth Army of the Philippines or recognized guerrilla organizations. Statutory authority is found in 38 U.S.C. 101 and 6104. Regulatory authority is found in 38 C.F.R. 3.40.

2. VA Form 21-4169 is used to gather the necessary information to determine whether a claimant’s service qualifies as service in the Commonwealth Army of the Philippines or recognized guerrilla organizations. The form is used for the sole purpose of collecting the information needed to determine eligibility for benefits based on such service, including service information, proof of service, place of residence, and membership in pro-Japanese, pro-German, or anti-American Filipino organizations.

3. VA Form 21-4169 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. This form solicits the information needed to determine whether benefits based on Commonwealth Army or recognized guerrilla service may be granted. Without this information, VA would be unable to properly 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 June 12, 2014, Volume 79, No. 113, page 33812. No comments were received in response to this notice.

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.

1. Number of Respondents is estimated at 1,000 per year.

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

3. Annual burden is 250 hours.

4. The estimated completion time of 15 minutes is based on review by staff personnel and previous usage of this form.

5. 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 $6,000.00 (250 burden hours x $24 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

1. Processing/Analyzing costs $41,070

(GS-9/5 @ $28.04 x 1,000 x 80/60 minutes = $37,387)

(GS-3/5 @ $14.73 x 1,000 x 15/60 minutes = $ 3,683)

2. Printing and production cost $25

3. Total cost to government $41,095

15. There is no change in the reporting burden. The expiration date placeholder has been added to the form.

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.