Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC) (VA Form 21P-0969)

Forms and Documents

Document Name	Status
Form VA Form 21P-0969 Income and Asset Statement in Support of Claim for Form	New
JS - 21P-0969 (New CR 12 30 14) 12.30.14.doc Supporting Statement A	2014-12-30

IC Document Collections

IC ID	Document Title	Status
214403	Income and Asset Statement in Support of Claim for Form	New

ICR Details

OMB Control No: 2900-0829	ICR Reference No: 201412-2900-019
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-NK (NEW)
Title: Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC) (VA Form 21P-0969)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule	Conclusion Date: 03/10/2015
	Date Received in OIRA: 01/02/2015
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		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Form 21P-0969 will be used by claimants for VA pension or Parents' Dependency and Indemnity Compensation (DIC) to provide information pertaining to income and assets to establish entitlement to pension or Parents' DIC. This form will be completed only by those claimants who had income other than Social Security benefits during the calendar year before claiming benefits or who disposed of assets or have significant assets.

---

Authorizing Statute(s): US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income
   US Code: 38 USC 1541 Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 1543 Name of Law: Net worth limitation
   US Code: 38 USC 1315 Name of Law: Dependency and indemnity compensation to parents
  

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
Income and Asset Statement in Support of Claim for	VA Form 21P-0969	Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC)

---

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: This is a new collection to support the changes in RIN 2900-AO73.

---

Annual Cost to Federal Government: $2,879,750

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:  No

---

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: 01/02/2015

---