Notice of Disagreement

Forms and Documents

Document Name	Status
Form 21-0958 Notice of Disagreement Form	New
Supporting Statement for VAF 21-0958 2-20-13-2.doc Supporting Statement A	2013-02-20

IC Document Collections

IC ID	Document Title	Status
202598	Notice of Disagreement Form	New

ICR Details

OMB Control No: 2900-0791	ICR Reference No: 201206-2900-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Notice of Disagreement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/22/2013
	Date Received in OIRA: 11/27/2012
Terms of Clearance: VA is reminded to display the OMB Control Number and the expiration date on the online/electronic versions of the form.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved
Responses	144,000	0	0
Time Burden (Hours)	72,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This is a new VA Form which will be used by the Veteran to indicate disagreement with a decision issued by a Regional Office (RO).

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Authorizing Statute(s): US Code: 38 USC 1521(d) and (e) Name of Law: Veterans of a period of war
   US Code: 38 USC 1114 Name of Law: Rates of wartime disability compensation
   US Code: 38 USC 1151(1)(E) Name of Law: Benefits for persons disabled by treatment or vocational rehabilitation
   US Code: 38 USC 1311(d) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1541(d) and (e) Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 7105(a) Name of Law: Filing notice of disagreement and appeal
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 42556	07/19/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 60027	10/01/2012
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Notice of Disagreement	21-0958	Notice of Disagreement

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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	144,000	0	0	144,000	0	0
Annual Time Burden (Hours)	72,000	0	0	72,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new data collection.

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Annual Cost to Federal Government: $7,218,864

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 11/27/2012

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