ELIGIBILITY VERIFICATION REPORT

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
147048	ELIGIBILITY VERIFICATION REPORT Form	Migrated

ICR Details

OMB Control No: 2900-0101	ICR Reference No: 198504-2900-009
Status: Historical Active	Previous ICR Reference No: 198404-2900-001
Agency/Subagency: VA	Agency Tracking No:
Title: ELIGIBILITY VERIFICATION REPORT
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/03/1985
	Date Received in OIRA: 04/04/1985
Terms of Clearance: APPROVED WITH THE FOLLOWING CHANGES: FOR MONTHLY PAYMENTS, GROSS INCOME WILL BE COLLECTED AND DEDUCTIONS WILL BE DELETED FROM ALL FORMS. INSTRUCTIONS WILL BE MODIFIED TO CLARIFY WHAT CONSTITUTES GROSS INCOME. THESE CHANGES ARE NECESSARY TO REDUCE REPORTING BURDENS ON ELDERLY VETERANS. THE MEDICAL EXPENSES SECTION WILL BE MODIFIED TO ADD A QUESTION ON HEALTH INSURANCE COVERAGE IN ORDER TO VALIDATE INFORMATION PROVIDED IN THIS SECTION. TO THE EXTENT THAT NET WORTH CAN BE BROKEN OUT INTO SUB-PARTS, IT WILL BE DONE.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/1986	09/30/1986	02/28/1986
Responses	1,600,000	0	1,600,000
Time Burden (Hours)	400,000	0	400,000
Cost Burden (Dollars)	0	0	0

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Abstract: THIS FORM IS REQUIRED TO OBTAIN ANNUALLY, CURRENT ELIGBILITY INFORMATION (INCOME, NET WORTH, MARITAL STATUS, ETC.) TO ENABLE THE VA TO DETERMINE THE BENEFICIARIES CONTINUED ENTITLEMENT TO PENSION BENEFI AND TO CALCULATE THE CURRENT RATE OF BENEFITS PAYABLE.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
ELIGIBILITY VERIFICATION REPORT	VA 21-4179, 21-8913, 21-8914, 21-8915, 21-8916, 21-8917, 21-8918, 21-8919

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ICR Summary of Burden

	Total Approved	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	1,600,000	1,600,000	0	0	0	0
Annual Time Burden (Hours)	400,000	400,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/04/1985

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