Veteran's Application for C&P, Veteran's Supplemental Claim Application, General Release for Med Provider Info to the Dept of VA, Authorization to Disclose Info to the Dept of VA (21-526,526b,4142 &a)

Forms and Documents

Document Name	Status
Form VA Form 21-526 Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application Form	Modified
2900-0001 -SuppStmt (12-30-14).docx Supporting Statement A	2014-12-30

IC Document Collections

IC ID	Document Title	Status
28062	Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application Form	Modified

ICR Details

OMB Control No: 2900-0001	ICR Reference No: 201412-2900-015
Status: Historical Inactive	Previous ICR Reference No: 201407-2900-015
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Veteran's Application for C&P, Veteran's Supplemental Claim Application, General Release for Med Provider Info to the Dept of VA, Authorization to Disclose Info to the Dept of VA (21-526,526b,4142 &a)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 03/04/2015
	Date Received in OIRA: 12/30/2014
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	08/31/2017
Responses	433,433	0	433,433
Time Burden (Hours)	149,182	0	149,182
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Forms 21-526 and 21-526b are used to gather the necessary information to determine a veteran's eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible. VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA.

---

Authorizing Statute(s): US Code: 38 USC Section 5101(a) Name of Law: Claims and forms
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO73	Proposed rulemaking	12 FR 345	12/30/2014

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application	VA Form 21-526, VA Form 21-526b, VA Form 21-4142, VA Form 21-4142a	Application for Compensation and/or Pension ,   Veteran's Supplemental Claim for Compensation ,   Authorization to Disclose Information to the Department of Veterans Affairs (VA) ,   General Release for Medical Provider Information to the Department of Veterans Affairs (VA)

---

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $4,188,575

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

---

Common Form ICR:  Yes

Description/Changes for Common Form Usage:  In RIN 2900-AO73, VA proposes to amend its pension regulations to maintain the integrity of its needs-based pension program. VA has authority under 38 U.S.C. 501(a) to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by VA. VA would amend its information collections consistent with RIN 2900-AO73. This rulemaking is largely in response to a Government Accountability Office (GAO) report, GAO-12-50, Veterans’ Pension Benefits: Improvements Needed to Ensure only Qualified Veterans and Survivors Receive Benefits. GAO 12-50 recommended that VBA modify its pension application forms and recommended an up-front verification process. VA has authority under 38 U.S.C. 5317 to use information from the Social Security Administration (SSA) and the Internal Revenue Service (IRS) in an up-front verification process. VA would amend its information collections consistent with the GAO recommendations and an up-front verification process with the SSA and IRS. Up-front verification also aids in VA compliance with the Improper Payment Elimination and Recovery Act (IPERA), Public Law 112-248.

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

---

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: 12/30/2014

---