JS - 21P-0969 (New CR 12 30 14) 12.30.14

Supporting Statement for

VA Form 21P-0969, Income and Asset Statement in Support of Claim for

Pension or Parents’ Dependency and Indemnity Compensation (DIC)

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. Information is requested by this form under the authority of 38 U.S.C. 1315, 1503, and 1541 through 1543.

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.

2. 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.

3. The form will be made available on the One-VA web site in a fillable electronic format. VBA does not have the technology in place to allow for the complete electronic submission of the form. There currently is no utility process in place that will allow the data submitted on the forms to be incorporated with an existing centralized legacy database. At this time, VA does not have the resources to add this form to VONAPP for electronic submission. However, as resources become available, VA will consider adding it to the eBenefits web portal.

4. Program reviews were conducted to identify potential areas of duplication. 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. This form is designed in a “user friendly” format, 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 XXXXXX at page XXXXXX. Comments/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 58VA21/22/28,‘‘Compensation, Pension, Education, and Vocational Rehabilitation and Employee Records—VA ’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009), and last amended by 75 FR 22187 (April 27, 2010), with other amendments, as cited therein.

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 60,000 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 25,000 hours.

d. The estimated completion time of 25 minutes is based on review by staff personnel.

e. 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 $600,000 (25,000 hours x $24/hour). VA completed a data request reviewing VA’s current corperate data of all claimants that have income other than Social Security and net worth of $10,000 or more. We were able to use that information to make an educated determination of the number of claimants that will use this form.

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $ 2,837,750

(GS-11/5 @ $47.86 * 60,000 * 25/60 minutes = $1,196,500)
(GS- 9/5 @ $39.55 * 60,000 * 25/60 minutes = $988,750)
(GS-5 /5 @ $26.10 * 60,000 * 25/60 minutes = $652,500)

b. Printing and production cost $42,000

c. Total cost to government $2,879,750

15. The expiration date placeholder has been added to the forms.

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 Veterans Benefits Administration does not collect information employing statistical methods.