Report of Income from Property or Business (VA Form 21P-4185)

Forms and Documents

Document Name	Status
Form 21P-4185 Report of Income from Property or Business Form	Modified
2900-0108 30-Day FRN.pdf Supplementary Document	2018-01-11
2900-0108 60-Day FRN.pdf Supplementary Document	2017-10-25
2900-0108 Supporting Statement.docx Supporting Statement A	2018-01-04

IC Document Collections

IC ID	Document Title	Status
28295	Report of Income from Property or Business Form	Modified

ICR Details

OMB Control No: 2900-0108	ICR Reference No: 201708-2900-009
Status: Active	Previous ICR Reference No: 201604-2900-014
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-DJ/YA
Title: Report of Income from Property or Business (VA Form 21P-4185)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/27/2018
	Date Received in OIRA: 02/09/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2021	36 Months From Approved	04/30/2018
Responses	7,000	0	7,000
Time Burden (Hours)	3,500	0	3,500
Cost Burden (Dollars)	83,510	0	84,000

---

Abstract: VA Form 21-4185 is used by veterans and survivors to report business and/or property income and expenses. Without this information, VA would be unable to determine eligibility to income-based benefits for claimants who have such income, and benefits would not be properly paid. VA has transferred control of this form to Pension and Fiduciary Service, so the VA Form Number is being updated accordingly.

---

Authorizing Statute(s): US Code: 38 USC 1541 Name of Law: Surviving Spouses of Veterans of a Period of War
   US Code: 38 USC 1315 Name of Law: Dependency and Indemnity Compensation to Parents
   US Code: 38 USC 1521 Name of Law: Veterans of a Period of War
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 49482	10/25/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 1288	01/10/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Report of Income from Property or Business	21P-4185	Report of Income from Property or Business

---

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	7,000	7,000	0	0	0	0
Annual Time Burden (Hours)	3,500	3,500	0	0	0	0
Annual Cost Burden (Dollars)	83,510	84,000	0	-490	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:

---

Annual Cost to Federal Government: $324,410

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.     Yes

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

---

Common Form ICR:  No

---

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: 02/09/2018

---