Statement of Marital Relationship (VA Form 21-4170)

ICR 202009-2900-015

OMB: 2900-0114

Federal Form Document

Forms and Documents
IC Document Collections
IC ID
Document
Title
Status
28314 Modified
ICR Details
2900-0114 202009-2900-015
Received in OIRA 201611-2900-010
VA VBA-COMP-NK
Statement of Marital Relationship (VA Form 21-4170)
Reinstatement with change of a previously approved collection   No
Regular 05/24/2021
  Requested Previously Approved
36 Months From Approved
2,205 0
919 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.

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

  86 FR 13968 03/11/2021
86 FR 26781 05/17/2021
Yes

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

  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 2,205 0 0 -4,295 0 6,500
Annual Time Burden (Hours) 919 0 0 -1,789 0 2,708
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The respondent burden has decreased due to the estimated number of receivables averaged over the past year.

$100,962
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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