Beneficiary Travel Mileage Reimbursement Application Form

Forms and Documents

Document Name	Status
Form VA Form 10-3542 VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES Form and Instruction	New
10-3542 10-23-13.pdf Supplementary Document	2013-10-23
Memo on revisions to 10-3542_10-9-13 (v3) (10.21.13).docx Supplementary Document	2013-10-21
10-3542 BT Claim Form __Minor-Rev Sept 24 (10.21.13).pdf Supplementary Document	2013-10-21
Justification_Beneficiary Travel Application (v2).docx Supporting Statement A	2013-08-20

IC Document Collections

IC ID	Document Title	Status
206581	VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES Form and Instruction	New

ICR Details

OMB Control No: 2900-0798	ICR Reference No: 201304-2900-019
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Beneficiary Travel Mileage Reimbursement Application Form
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2013
	Date Received in OIRA: 08/29/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved
Responses	11,600,000	0	0
Time Burden (Hours)	580,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information collection is for beneficiaries to apply for the BT mileage reimbursement benefit. VHA determines the identity of the claimant, the dates and length of the trip being claimed based on addresses of starting and ending points, , and whether expenses other than mileage are being claimed. The claimant is required to sign the form. The form is used only when the claimant chooses not to apply verbally and is provided for their convenience. Once the information is obtained it is entered into a software program that calculates the mileage and resulting reimbursement.

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Authorizing Statute(s): US Code: 38 USC Section 111 Name of Law: Payments or allowances for beneficiary travel
  

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:
	78 FR 115	06/14/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 168	08/29/2013
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
VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES	VA Form 10-3542	VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES

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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	11,600,000	0	0	0	0	11,600,000
Annual Time Burden (Hours)	580,000	0	0	0	0	580,000
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: $1,500,000

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: 08/29/2013

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