Statement of Marital Relationship (VA Form 21-4170)

Forms and Documents

Document Name	Status
Form VA Form 21-4170 Statement of Marital Relationship (21-4170) Form	Modified
2017-17462, 30-Day FRN (2900-0114).pdf Supplementary Document	2017-09-22
2900-0114 Supporting Stmt (VAF 21-4170).docx Supporting Statement A	2017-09-22
2900-0114__60-day FRN (Published 03-07-17).pdf Supplementary Document	2017-03-07

IC Document Collections

IC ID	Document Title	Status
28314	Statement of Marital Relationship (21-4170) Form	Modified

ICR Details

OMB Control No: 2900-0114	ICR Reference No: 201611-2900-010
Status: Historical Active	Previous ICR Reference No: 201312-2900-015
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DJ
Title: Statement of Marital Relationship (VA Form 21-4170)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/14/2017
	Date Received in OIRA: 09/22/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	36 Months From Approved	11/30/2017
Responses	6,500	0	6,500
Time Burden (Hours)	2,708	0	2,708
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Form 21-4170 is used to gather information that is necessary to determine whether a valid common law marriage was established. The form is used by persons claiming to be common law surviving spouses of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established. VA Form 21-4170 is being revised to include new standardization data points; to include optical character recognition boxes. This is a non-substantive change.

---

Authorizing Statute(s): US Code: 38 USC 103(c) Name of Law: Special provisions relating to marriages.
   US Code: 38 USC 101(3) and 101(31) Name of Law: Definitions
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12916	03/07/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 39489	08/18/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Statement of Marital Relationship (21-4170)	VA Form 21-4170	Statement of Marital Relationship

---

ICR Summary of Burden

	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	6,500	6,500	0	0	0	0
Annual Time Burden (Hours)	2,708	2,708	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $351,975

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 09/22/2017

---