2900-0114 Supporting Stmt (VAF 21-4170)

Supporting Statement for VA Form 21-4170

Statement of Marital Relationship

OMB 2900-0114

A. Justification

1. 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. Certain veterans who are entitled to VA compensation and/or pension benefits may be entitled to an additional allowance for a spouse, and surviving spouses of deceased veterans may be entitled to VA death benefits. A valid marriage must be established. Information is requested by this form under the authority of 38 U.S.C. 101(3), 38 U.S.C. 101(31), and 38 U.S.C. 103(c) which provide that a marriage is valid for VA purposes if it is valid under the law of the place where the parties resided at the time of the marriage, provided the marriage is between persons of the opposite sex. A number of states recognize common law marriages.

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.

2. 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 21-4170 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 widows/widowers of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established.

3. 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 21-4170 is available on the One-VA Website in a fillable electronic format. VBA is currently hosting these forms on a secure server and does not currently have the technology in place to allow for the complete submission of the forms. 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 forms to be incorporated with an existing centralized legacy database.

4. 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.

5. 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.

6. 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.

The VA compensation and pension programs require current information to determine eligibility for benefits. Without the information provided on this form, VA would be unable to determine whether claimants had established a common law marriage and authorize benefits.

7. 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.

8. 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 7, 2017, Volume 82, No. 43, Pages 12916 and 12917. One comment was received in response to this notice. The anonymous commenter gave a compliment on the data collection.

9. 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.

10. 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).

11. 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.

12. Estimate of the hour burden of the collection of information:

Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 6,500 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 2,708 hours.

d. The estimated completion time of 25 minutes.

e. The respondent population for VA Form 21-4170 is composed of individuals who are seeking to establish a valid common law marriage for VA purposes. The form is used by persons claiming to be common law widows/widowers of deceased veterans and by veterans and their claimed common law spouses. 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 $954.40. Assuming a forty (40) hour work week, the mean hourly wage is $23.86 based on the BLS wage code – “00-0000 All Occupations.” This information was taken from the following website: (http://www.bls.gov/oes/current/oes_nat.htm#00-0000, May 2016).

Legally, respondents may not pay a person or business for assistance 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 $64,612.88 (2,708 burden hours x $23.86 per hour).

13. 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).

This submission does not involve any recordkeeping costs.

14. 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:

Grade	Step	Burden Time	Fraction of Hour	Hourly Rate	Cost Per Response	Total Responses	Total
7	3	30	0.50	$18.07	9.035	6,500	$ 58,727.50
Overhead at 100% Salary							$ 58,727.50
9	3	30	0.50	$22.11	11.055	6,500	$ 71,857.50
Overhead at 100% Salary							$ 71,857.50
11	3	15	0.25	$26.75	6.688	6,500	$ 43,468.75
Overhead at 100% Salary							$ 43,468.75
Processing / Analyzing Costs							$ 348,107.50
Printing and Production Cost							$ 3,867.86
Total Cost to Government							$ 351,975.36

Overhead costs are 100% of salary and are same as the wage listed above and the amounts are included in the total.

Note: The hourly wage information above is based on the hourly 2017 General Schedule (Base) Pay (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2017/GS_h.pdf ). This rate does not include any locality adjustment as applicable.

The processing time estimates above are based on the actual amount of time employees of each grade level spend to process to completion a claim received on this form. The within-grade step (3) of each employee represents the average experience of employees within each grade.

15. Explain the reason for any burden hour changes since the last submission.

There is no change in the respondent burden. 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.

16. 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.

17. 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.

18. 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

This collection of information does not employ statistical methods.

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