Income Verification

Forms and Documents

Document Name	Status
Form 200-1A Income Verification Form	New
Justification - Final - 032817.docx Supporting Statement A	2018-05-03

IC Document Collections

IC ID	Document Title	Status
221774	Income Verification Form	New

ICR Details

OMB Control No: 2900-0867	ICR Reference No: 201606-2900-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Income Verification
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 without change	Conclusion Date: 06/17/2019
	Date Received in OIRA: 10/11/2018
Terms of Clearance: This information collection is approved for a period of one year consistent with the expectation that the Program Office shall conduct an analysis of the feasibility of reducing burden on respondents who would remain in the same priority group or move to a high priority group based on their IRS/SSA data. VA shall display the expiration data of this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved
Responses	273,441	0	0
Time Burden (Hours)	119,993	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: VHA Directive 1909 provides policy for the Income Verification (IV) Program. AUTHORITY: 38 United States Code (U.S.C.) 1722; 38 U.S.C. 5317. Title 38 U.S.C. 1722 established eligibility assessment procedures, based on income levels, for determining whether nonservice-connected (NSC) Veterans and non-compensable zero percent service-connected (SC) Veterans, who have no other special eligibility are eligible to receive Department of Veterans Affairs (VA) health care at no cost. Title 26 U.S.C. 6103 (l)(7) of the Internal Revenue Code, and 38 U.S.C. 5317 establish authority for VA to verify Veterans’ gross household income information against records maintained by the Internal Revenue Service (IRS) and Social Security Administration (SSA) when that information indicates the Veteran is eligible for cost-free VA health care. The IV Program must adhere to stringent confidentiality guidelines set forth by IRS and SSA to ensure appropriate security and safeguarding of FTI. Information received from the income match activity cannot be shared with VA medical facilities. Any breach of security requirements may result in loss of VHA’s matching agreements with IRS and SSA. Veteran requests for release of IV financial assessments and related information must be forwarded to HEC for processing.

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Authorizing Statute(s): None

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:
	82 FR 8566	01/26/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 16474	04/04/2017
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
Income Verification	340-1, 220-1, 200-1A	Income Verification Response ,   Spouse - Income Verification Response ,   Declaration of Representative

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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	273,441	0	0	273,441	0	0
Annual Time Burden (Hours)	119,993	0	0	119,993	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 collection which shouldn't show an increase in the burden.

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Annual Cost to Federal Government: $246,097

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 10/11/2018

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