Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)

ICR 202010-2900-011

OMB: 2900-0856

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2021-02-09
Supporting Statement A
2021-02-09
Supplementary Document
2020-12-22
IC Document Collections
IC ID
Document
Title
Status
220731 Modified
ICR Details
2900-0856 202010-2900-011
Received in OIRA 201507-2900-007
VA VBA-INS-NK
Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)
Reinstatement with change of a previously approved collection   No
Regular 02/09/2021
  Requested Previously Approved
36 Months From Approved
1,200 0
100 0
0 0

This form will be used by the Department of Veterans Affairs Insurance Center (VAIC) to enable a third party to act on behalf of the insured Veteran/beneficiary. Many of our customers are of advanced age or suffer from limiting disabilities and need assistance from a third party to conduct their affairs. The information collected provides an optional service and is not required to receive insurance benefits.

None
None

Not associated with rulemaking

  85 FR 24308 11/03/2020
86 FR 2650 02/09/2021
No

1
IC Title Form No. Form Name
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION VA Form 29-0975 Authorization to Disclose Personal Information to a Third Party (Insurance)

  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 1,200 0 0 0 0 1,200
Annual Time Burden (Hours) 100 0 0 100 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
There is a small increase due to an increase in use of this form.

$6,630
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.
02/09/2021


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