Employment Certification Form

EMPLOYMENT CERTIFICATION FORM (VA Form 22-10201)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0874 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 22-10201 Employment Certification Form Form
VA Form 22-10201 Employment Certification Form 22-10201(5-5-21).pdf www.va.gov/vaforms Form
VA Form 22-10201 Employment Certification Form 22-10201(5-5-21).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

IC Title:	Employment Certification Form	Agency IC Tracking Number:	2900-0874

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 22-10201	Employment Certification Form	22-10201(5-5-21).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Education

Subfunction: Elementary, Secondary, and Vocational Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 750	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	562,500	562,500
Annual IC Time Burden (Hours)	46,875	46,875
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.