Employment Questionnaire (VA Form 21-4140)

ICR 202009-2900-012

OMB: 2900-0079

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2021-05-20
Supplementary Document
2021-03-11
Supporting Statement A
2021-05-05
IC Document Collections
IC ID
Document
Title
Status
28229 Modified
ICR Details
2900-0079 202009-2900-012
Received in OIRA 201702-2900-003
VA VBA-COMP-YA
Employment Questionnaire (VA Form 21-4140)
Reinstatement without change of a previously approved collection   No
Regular 05/24/2021
  Requested Previously Approved
36 Months From Approved
2,960 0
247 0
0 0

VA Forms 21-4140 is used to gather the necessary information to determine continued entitlement to individual unemployability. 38 CFR 3.652 provides that recipients are required to certify, when requested, that the eligibility factors which established entitlement to the benefit being paid continue to exist. Individual unemployability is awarded based on a veteran’s inability to be gainfully employed due to service-connected disabilities, and entitlement may be terminated if a veteran begins working. Without information about recipients’ employment, VA would not be able to determine continued entitlement to individual unemployability, and overpayments would result. The respondent burden has decreased due to the removal of one of the forms listed within this collection. This collection used to include; • VA Form 21-4140, and • VA Form 21-4140-1. VA Form 21-4140 was only available as a computer -generated form which was dispatched as a monthly batch print through VA’s central computer system. VA Form 21-4140-1 was available on the One-VA website, for the usability of the claimant should they not receive the batch printed form. However, the batch print for VA Form 21-4140 is no longer in use. Thus, the two forms were combined into one form number, called VA Form 21-4140. This collection will now be associated with the one form number. No changes have been made to VA Form 21-4140.

US Code: 38 USC 5317 Name of Law: Use of income information from other agencies: notice and verification
   US Code: 38 USC 501 Name of Law: Rules and regulations
  
None

Not associated with rulemaking

  86 FR 13969 03/11/2021
86 FR 26783 05/17/2021
No

1
IC Title Form No. Form Name
Employment Questionnaire (VA Form 21-4140) 21-4140 Employment Questionnaire

  Total Request 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 2,960 0 0 -127,040 0 130,000
Annual Time Burden (Hours) 247 0 0 -10,586 0 10,833
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The respondent burden has decreased due to the removal of one of the forms listed within this collection.

$57,608
No
    Yes
    Yes
No
No
No
No
Maribel Aponte 202 266-4688 maribel.aponte@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.
05/24/2021


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