Alternate Signer Certification (VA Form 21-0972)

ICR 201603-2900-010

OMB: 2900-0849

Federal Form Document

Forms and Documents
Document
Name
Status
Form
New
Supplementary Document
2016-06-09
Supporting Statement A
2016-06-02
Supplementary Document
2016-03-25
IC Document Collections
IC ID
Document
Title
Status
220635 New
ICR Details
2900-0849 201603-2900-010
Historical Active
VA VBA-COMP-NK
Alternate Signer Certification (VA Form 21-0972)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/11/2016
Retrieve Notice of Action (NOA) 07/18/2016
  Inventory as of this Action Requested Previously Approved
10/31/2019 36 Months From Approved
5,000 0 0
1,250 0 0
0 0 0

VA Form 21-0972 will be used to collect the alternate signer information necessary for VA to accept benefit application forms signed by individuals on behalf of Veterans and claimants. The information collected will be used to contact the alternate signer for verification purposes.

US Code: 38 USC 5101 Name of Law: Claims and Forms
   PL: Pub.L. 112 - 154 502 Name of Law: Authority for certain persons to sign claims filed with VA on behalf of claimants
  
None

Not associated with rulemaking

  81 FR 6735 03/25/2016
81 FR 13395 06/07/2016
No

1
IC Title Form No. Form Name
Alternate Signer Certification VA Form 21-0972 Alternate Signer Certification

  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 5,000 0 0 5,000 0 0
Annual Time Burden (Hours) 1,250 0 0 1,250 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new form VA developed in response to Public Law 112-154, which allows for the appointment of alternate signers. Currently, we do not have a form for collecting alternate signer information, which is necessary for contacting and verifying individuals signing forms on behalf of Veterans and claimants.

$111,400
No
No
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 cynthia.harvey-pryor@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.
07/18/2016


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