Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance- VA Forms 29-4125 & 4125A

Forms and Documents

Document Name	Status
Form VA Form 29-4125 Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance Form	Modified
2900-0060(SupportState).doc Supporting Statement A	2016-12-06

IC Document Collections

IC ID	Document Title	Status
28196	Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance Form	Modified

ICR Details

OMB Control No: 2900-0060	ICR Reference No: 201602-2900-027
Status: Historical Active	Previous ICR Reference No: 201305-2900-017
Agency/Subagency: VA	Agency Tracking No: VBA-INS-NK
Title: Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance- VA Forms 29-4125 & 4125A
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: 12/16/2016
	Date Received in OIRA: 07/26/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	12/31/2016
Responses	120,100	0	84,350
Time Burden (Hours)	12,010	0	8,510
Cost Burden (Dollars)	0	0	0

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Abstract: The VA Forms 29-4125 and 29-4125A are used by beneficiaries to request the proceeds from Government Life Insurance policies. The information is required by law, 38 U.S.C. 1917 and 1952.

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Authorizing Statute(s): US Code: 38 USC 1952 Name of Law: Optional Settlement
   US Code: 38 USC 1917 Name of Law: Insurance Maturing on or after August 1, 1946
  

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 6645	03/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 17342	07/22/2016
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
Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance	VA Form 29-4125, VA Form 29-4125a	Claim for One Sum Payment (Government Life Insurance) ,   Claim for Monthly Payments National Life Insurance

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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	120,100	84,350	0	35,750	0	0
Annual Time Burden (Hours)	12,010	8,510	0	3,500	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: The increase in burden hours is due to the fact that unfortunately, as more veterans pass way, more forms are submitted to claim the proceeds from Government Life Insurance policies.

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Annual Cost to Federal Government: $640,253

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: 07/26/2016

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