VA Form 21-0972
OMB 2900-0XXX
JUSTIFICATION:
Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
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. VA interpreted 38 U.S.C. § 5101 to require a signature of a claimant on an original claim in order to pay benefits. On August 6, 2012, the President signed into law PL 112-154, Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012. Section 502 of this law, amends 38 U.S.C. § 5101, to allow for authorized individuals to sign a form or application on behalf of unable claimants and beneficiaries.
The alternative signer information necessary for VA to accept signatures of individuals on behalf of Veterans filing for benefits is captured on the new VA Form 21-0972, Alternate Signer Certification. A properly executed VA Form 21-0972 is required for individuals signing a benefit application form on behalf of the Veteran/claimant. The requested information is needed to determine entitlement to act as the alternate signer for a Veteran/claimant in submitting a claim for VA benefits.
Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.
VA Form 21-0972 is 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.
Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
VA Form 21-0972 will be 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.
Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
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.
If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
The collection of information does not involve small businesses or entities.
Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.
Without the information provided on VA Form 21-0972, VA would be unable to verify information related to the alternate signer who has been appointed to represent the claimant in the prosecution of VA claims, the extent of such representation, and access to appropriate records.
Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.
There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
A. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.
The Department notice was published in the Federal Register on March 25, 2016, Volume 81, No. 58, pages 16282 & 16283. No comments were received in response to this notice.
Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.
This submission does not involve any recordkeeping costs.
Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payments or gifts to respondents have been made under this collection of information.
Describe any assurance of privacy to the extent permitted by law provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22/28, “Compensation, Pension, Education, and Rehabilitation Records—VA” as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
There are no questions of a sensitive nature.
Estimate of the hour burden of the collection of information:
Estimate of Information Collection Burden.
Number of Respondents: 5,000
Frequency of Response: One time
Annual Burden Hours: 1,250
Estimated Completion Time: 15 minutes
The respondent population for VA Form 21-0972 is composed of individuals who may be entitled to aid on behalf of a Veteran/claimant in their claim(s) for benefits. VBA cannot make further assumptions about the population of respondents because of the variability of factors such as the educational background and wage potential of respondents. Therefore, VBA used general wage data to estimate the respondents’ costs associated with completing the information collection.
The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the median weekly earnings of full-time wage and salary workers are $809.00. Assuming a forty (40) hour work week, the median hourly wage is $20.23.
Legally, respondents may not pay a person or business for assistance in completing the information collection and a person or business may not accept payment for assisting a respondent in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $25,288.00 (1,250 burden hours x $20.23 per hour).
Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
There is no capital, start-up, operation or maintenance costs.
Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.
There are no anticipated capital start-up cost components or requests to provide information.
Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.
Estimated Costs to the Federal Government:
Processing/Analyzing Costs with Overhead $110,176.00
(GS-9/3 @ $26.55 x 5,000 x 15/60 minutes = $33,188.00
Overhead at 100% of Salary= $33,188.00
(GS-5/3 @ $17.52 x 5,000 x 15/60 minutes = $21,900.00
Overhead at 100% of Salary= $21,900.00
Overhead costs are 100% of salary and are same as the wage listed above and the amounts are included in the total.
Printing and production cost ($90/thousand) $1,224.00
Total cost to government $111,400.00
Explain the reason for any burden hour changes since the last submission.
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.
For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.
The information collection is not for publication or tabulation use.
If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
We are not seeking approval to omit the expiration date for OMB approval.
Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
No statistical methods are used in this data collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for VA Form 21-4502 |
| Author | VBA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |