Marital Status Questionnaire (21P-0537)

Forms and Documents

Document Name	Status
Form 21P-0537 Marital Status Questionnaire Form	Modified
2900-0495 30-Day FRN.pdf Supplementary Document	2016-06-07
2900-0495 60-Day FRN.pdf Supplementary Document	2016-03-30
2900-0495 Revisions Description.docx Supplementary Document	2016-03-17
2900-0495 Supporting Statement_final.docx Supporting Statement A	2016-09-22

IC Document Collections

IC ID	Document Title	Status
28678	Marital Status Questionnaire Form	Modified

ICR Details

OMB Control No: 2900-0495	ICR Reference No: 201602-2900-003
Status: Historical Active	Previous ICR Reference No: 201406-2900-022
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-YM
Title: Marital Status Questionnaire (21P-0537)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/26/2016
	Date Received in OIRA: 06/09/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved	09/30/2016
Responses	17,808	0	2,286
Time Burden (Hours)	1,484	0	191
Cost Burden (Dollars)	30,021	0	0

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Abstract: VA Form 21P-0537 is used to verify a surviving spouse’s current marital status to verify his or her continuing entitlement to DIC benefits. The form letter is automatically generated and mailed to DIC beneficiaries. Agency action depends on the information provided by the beneficiary. If the information provided supports the beneficiary’s continued entitlement to benefits, no action is taken. If the information provided by the beneficiary does not support continued entitlement to benefits, VA will take action to terminate benefit payments, based on the facts found.

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Authorizing Statute(s): US Code: 38 USC 103 Name of Law: Special Provisions Relating to Marriages
   US Code: 38 USC 101(3) Name of Law: Definition of Surviving Spouse
  

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:
	81 FR 16283	03/25/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 36661	06/07/2016
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
Marital Status Questionnaire	21P-0537	Marital Status Questionnaire

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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	17,808	2,286	0	15,522	0	0
Annual Time Burden (Hours)	1,484	191	0	1,293	0	0
Annual Cost Burden (Dollars)	30,021	0	0	30,021	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: VBA re-estimated the annual number of respondents based on real claim data contained in our benefits database. The estimated completion time of five (5) minutes has not increased since the last submission.

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Annual Cost to Federal Government: $62,507

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: 06/09/2016

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