SuppStmt, VAF 21-0966, 7-30-14

Supporting Statement for:

(2900-XXXX)

VA Form 21-0966

Intent to File a Claim for Compensation and/or Pension, Survivors Pension, or Other Benefits

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. 5102 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. The amended collection of information in the final rule 38 CFR 3.155 would require claimants and/or their authorized representatives to submit a VA-prescribed form in either paper or electronic submission, where applicable, to express a claimant’s intent to file a claim for benefits in order to establish an effective date placeholder for any award granted if the claimant files a complete claim within 1 year of receipt of the intent to file a claim. VA proposes to create a new form, VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension Benefits, Survivors Pension, or Other Benefit. Claimants and their representatives can submit their intent to file a claim in three ways: (1) on paper using VA’s newly created, proposed VA Form 21-0966; (2) electronically through a claims submission tool within a VA Web-based electronic claims application system; or, (3) by telephone contact with VA personnel who will record the intent to file a claim on the proposed VA Form 21-0966.

The Final Rule RIN 2900-AO81, Standard Claims and Appeals Forms, which requires all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA is codifying its regulations to standardize the use of all VA forms, to include VA Forms 21-0966.

2. 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. VA will use this form to identify claimants in its internal business operational systems to record the date of receipt of this document for the purposes of establishing a date of claim for a complete claim that is filed within 1 year. VA also uses the information to furnish the claimant with the appropriate VA form or application for VA benefits.

3. VA Form 21-0966 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 proposed rule, RIN 2900-AO81, Standard Claims and Appeals Forms, in the Federal Register on October 31, 2013, Vol. 78, No. 211, pages 65490-65509. 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 totals = 724,561:

2. Frequency of Response is one time.

3. Annual burden total = 181,140 hours.

4. The estimated completion time is 15 minutes.

5. According to the U.S. Bureau of Labor Statistics, Average Hourly Earnings, the cost to the respondent is $24 per hour, making the total cost to the respondents an estimated $4,347,360 (181,140 burden hours x $24 per hour).

13. VA recognizes there may be costs with 3^rd party assistance. VA requests input from the public.

14. Estimated Costs to the Federal Government:

1. Processing/Analyzing costs $5,079,172

(GS- 9/5 @ $28.04 x 724,561 x 15/60 minutes = $5,079,173)

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

3. Printing and production cost ($90/thousand) $56,435

4. Total cost to government $5,135,607

15. The burden is due to the Final Rule RIN 2900-AO81, Standard Claims and Appeals Forms which requires all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA is codifying its regulations to standardize the use of all VA forms, to include VA Form 21-0966. Currently, other than for the initial original claim, VA does not require that claimants submit any subsequent claim on a prescribed VA 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

The data collection does not employ statistical methods.