Statement of Marital Relationship (VA Form 21-4170)

ICR 201611-2900-010

OMB: 2900-0114

Federal Form Document

Forms and Documents
IC Document Collections
IC ID
Document
Title
Status
28314 Modified
ICR Details
2900-0114 201611-2900-010
Historical Active 201312-2900-015
VA VBA-COMP-DJ
Statement of Marital Relationship (VA Form 21-4170)
Extension without change of a currently approved collection   No
Regular
Approved without change 11/14/2017
Retrieve Notice of Action (NOA) 09/22/2017
  Inventory as of this Action Requested Previously Approved
11/30/2020 36 Months From Approved 11/30/2017
6,500 0 6,500
2,708 0 2,708
0 0 0

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.

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
  
None

Not associated with rulemaking

  82 FR 12916 03/07/2017
82 FR 39489 08/18/2017
Yes

1
IC Title Form No. Form Name
Statement of Marital Relationship (21-4170) VA Form 21-4170 Statement of Marital Relationship

  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
No
No

$351,975
No
    Yes
    Yes
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.
09/22/2017


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