Intent to File a Claim for Compensation and/or Pension, Survivors Pension, or Other Benefits (VA Form 21-0966)

Forms and Documents

Document Name	Status
Form VA Form 21-0966 INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, SURVIVORS PENSION, OR OTHER BENEFITS Form	New
SuppStmt, VAF 21-0966, 7-30-14.docx Supporting Statement A	2014-07-30

IC Document Collections

IC ID	Document Title	Status
212535	INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, SURVIVORS PENSION, OR OTHER BENEFITS Form	New

ICR Details

OMB Control No: 2900-0826	ICR Reference No: 201407-2900-019
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: 2900-NEW - COMP-NK
Title: Intent to File a Claim for Compensation and/or Pension, Survivors Pension, or Other Benefits (VA Form 21-0966)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/17/2014
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/19/2014
	Date Received in OIRA: 07/30/2014
Terms of Clearance: VA shall seek public comment and submit an extension of this collection within six months if it wishes to continue to collect this information.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2015	6 Months From Approved
Responses	724,561	0	0
Time Burden (Hours)	181,140	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-0966 will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or disability benefits to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.

Emergency Justfication: Resubmited due to form revision.

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Authorizing Statute(s): US Code: 38 USC 5102 Name of Law: Application forms furnished upon request; notice to claimants of incomplete applications
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO81	Final or interim final rulemaking	79 FR 57660	09/25/2014

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Federal Register Notices & Comments

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
INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, SURVIVORS PENSION, OR OTHER BENEFITS	VA Form 21-0966	Intent to File a Claim for Compensation or Pension, Survivors Pension, or Other Benefits

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ICR Summary of Burden

	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	724,561	0	0	724,561	0	0
Annual Time Burden (Hours)	181,140	0	0	181,140	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: The respondent burden increases because VA Form 21-0966 is a new form and will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or disability benefits to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.

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Annual Cost to Federal Government: $5,135,607

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)? No

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: 07/30/2014

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