Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)

Forms and Documents

Document Name	Status
Form VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC Form	Modified
201501-2900-006_2900-0826 SuppStmt (21-0966) (7-7-15).docx Supporting Statement A	2015-07-07

IC Document Collections

IC ID	Document Title	Status
212535	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC Form	Modified

ICR Details

OMB Control No: 2900-0826	ICR Reference No: 201501-2900-006
Status: Historical Active	Previous ICR Reference No: 201407-2900-019
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)
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: 07/09/2015
	Date Received in OIRA: 05/22/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2015
Responses	724,561	0	724,561
Time Burden (Hours)	181,140	0	181,140
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-0966 will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or pension, or survivors pension and/or DIC, to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.

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Authorizing Statute(s): US Code: 38 USC 5102 Name of Law: Application forms furnished upon request; notice to claimants of incomplete applications
  

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:
	80 FR 27	02/10/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 89	05/08/2015
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
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	VA Form 21-0966	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

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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	724,561	724,561	0	0	0	0
Annual Time Burden (Hours)	181,140	181,140	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: $5,135,608

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: 05/22/2015

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