2900-0001 -SuppStmt (12-30-14)

Supporting Statement for:

(2900-0001)

VA Form 21-526	Veteran’s Application for Compensation and/or Pension
VA Form 21-526b	Veteran’s Supplemental Claim Application
VA Form 21-4142a	General Release for Medical Provider Information to the Department of Veterans Affairs (VA)
VA Form 21-4142	Authorization and Consent to Release Information to the Department of Veterans Affairs

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. 5101(a) 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. VA Form 21-526 is the prescribed form for initial disability claims. VA Form 21-526b is the prescribed form for supplemental disability or ancillary benefit claims. VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather private provider information of the Veteran to VA.

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-12-540, Veterans’ Pension Benefits: Improvements Needed to Ensure only Qualified Veterans and Survivors Receive Benefits.

GAO 12-540 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.

2. VA Form 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. In order to expedite and streamline the claims adjudication process, VA codifies the requirement that claimants submit these forms to claim compensation and/or pension benefits on VA Form 21-526 or supplemental benefits on VA Form 21-526b in its adjudication regulations.

3. VA Forms 21-4142, 21-4142a, 21-526, and 21-526b are 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 are formatted as “user friendly” forms, 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 the Federal Register on (Insert Date) (Volume___, No. ___) (page/pages) (Insert Page Number(s)). (No or number) 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 “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 = 433,433:

   1. 83,855 for VA Form 21-526,

   2. 217,178 for VA Form 21-526b

   3. 66,200 for VA Form 21-4142, and

   4. 66,200 for VA Form 21-4142a.

2. Frequency of Response is one time.

3. Annual burden total = 149,182:

   1. 83,855 for VA Form 21-526,

   2. 54,295 for VA Form 21-526b,

   3. 5,516 for VA Form 21-4142, and

   4. 5,516 for VA Form 21-4142a.

4. The estimated completion time is:

   1. 60 minutes for VA Form 21-526,

   2. 15 minutes for VA Form 21-526b,

   3. 5 minutes for VA Form 21-4142, and

   4. 5 minutes for VA Form 21-4142a.

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 $3,580,368 (149,182 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:

a. Processing/Analyzing costs $4,183,085

• (GS- 9/5 @ $28.04 x 83,855 x 60/60 minutes = $2,351,294)

• (GS- 9/5 @ $28.04 x 217,178 x 15/60 minutes = $1,522,417)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

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

c. Printing and production cost ($90/thousand) $5,490

d. Total cost to government $4,188,575

15. 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.

The expiration date was added to these forms, in the previous approval.

Changes made to VA Form 21-526:

1. Wording and definitions were changed/added to reflect current terminology/processes.

2. Part VII was altered to instruct the Veteran when medical evidence is needed and to complete and attach VA Form 21-2680, Exam for Housebound Status or Permanent Need for Regular Aid and Attendance, signed by a physician (or other acceptable signatures) if claiming special monthly pension.

3. In Part VIII, VA asks the claimant to provide general information about income and assets. If a claimant responds ‘yes’ to any question from 37B though 38E, the form directs them to complete VA Form 21P-0969, Income and Asset Statement. Previously, claimants were required to disclose all income and asset information on VA Form 21-526.

4. Part IX was altered to add a block entitled ‘Hourly Rate/Hours (In-home attendant only). This block was added so the Veteran could report this information to claim In-home care as an unreimbursed medical expense.

5. Two worksheets were added to VA Form 21-526. The first worksheet is to be completed if the Veteran claims expenses from an assisted living, adult day care or similar facilities. The second worksheet is to be completed if the Veteran claims expenses for In-home care.

16. We are not seeking approval to omit the expiration date for OMB approval.

17. The information collection is not for publication or tabulation use.

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.