Notice of Disagreement (VA Form 21-0958)

ICR 201504-2900-001

OMB: 2900-0791

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2015-08-14
Supporting Statement A
2015-07-16
IC Document Collections
IC ID
Document
Title
Status
202598 Modified
ICR Details
2900-0791 201504-2900-001
Historical Active 201401-2900-003
VA VBA-COMP-NK
Notice of Disagreement (VA Form 21-0958)
Revision of a currently approved collection   No
Regular
Approved without change 09/28/2015
Retrieve Notice of Action (NOA) 08/17/2015
  Inventory as of this Action Requested Previously Approved
09/30/2018 36 Months From Approved 03/31/2016
144,000 0 144,000
72,000 0 72,000
0 0 0

VA Form 21-0958 is used by the claimant to indicate disagreement with a decision issued by a Regional Office (RO) in order to initiate an appeal.

US Code: 38 USC 1521(d) and (e) Name of Law: Veterans of a period of war
   US Code: 38 USC 1114 Name of Law: Rates of wartime disability compensation
   US Code: 38 USC 1151(1)(E) Name of Law: Benefits for persons disabled by treatment or vocational rehabilitation
   US Code: 38 USC 1311(d) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1541(d) and (e) Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 7105(a) Name of Law: Filing notice of disagreement and appeal
  
None

Not associated with rulemaking

  80 FR 83 04/30/2015
80 FR 148 08/03/2015
Yes

1
IC Title Form No. Form Name
Notice of Disagreement (21-0958) VA Form 21-0958 Notice of Disagreement

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 144,000 144,000 0 0 0 0
Annual Time Burden (Hours) 72,000 72,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$7,296,744
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 crystal.rennie@va.gov

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/17/2015


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