Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution

Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0116 can be found here:

Documents and Forms

Document Name Document Type
Form VA 21-4193 Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution Form
VA 21-4193 Notice to Department of Veterans Affairs of Veteran or B VBA-21-4193-ARE 12-21-2016.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

IC Title:	Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution	Agency IC Tracking Number:	2900-0116 VBA-COMP-YM

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA 21-4193	Notice to Department of Veterans Affairs of Veteran or Benefiiciary Incarcerated in Penal Institution	VBA-21-4193-ARE 12-21-2016.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,664	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,664	1,664
Annual IC Time Burden (Hours)	416	416
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.