Application Request to Add and/or Remove Dependents (VA Form 21-686c)

Forms and Documents

Document Name	Status
Form 21-686c Application Request to Add and/or Remove Dependents (VA Form 21-686c) Form	Modified
2018-12329, 30-Day FRN (2900-0043).pdf Supplementary Document	2018-08-01
2018-03333, 60-Day FRN (2900-0043).pdf Supplementary Document	2018-08-01
2900-0043, Supporting Stmt (VAF 21-686c).docx Supporting Statement A	2018-08-01

IC Document Collections

IC ID	Document Title	Status
28162	Application Request to Add and/or Remove Dependents (VA Form 21-686c) Form	Modified

ICR Details

OMB Control No: 2900-0043	ICR Reference No: 201808-2900-002
Status: Active	Previous ICR Reference No: 201610-2900-006
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Application Request to Add and/or Remove Dependents (VA Form 21-686c)
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: 09/10/2018
	Date Received in OIRA: 08/01/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved	06/30/2020
Responses	226,000	0	226,000
Time Burden (Hours)	113,000	0	56,500
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-686c is used to obtain current information about marital status and dependent child(ren). The information is needed to determine the correct rate of payment for veterans and beneficiaries who may be entitled to an additional allowance for dependents or to remove dependents. Substantive and non-substantive changes have been added to VA Form 21-686c. They include the following: • A new title • Non-substantive changes, to include: o New standardization data points; to include optical character recognition and section headings o A notice that provides information about evidence that is needed to support a claim for additional benefits for a dependent or to remove a dependent • An ‘Addendum’ that allows additional space to add more children • Substantive changes were added to clarify a more defined space to remove a spouse or child(ren) due to divorce, death, marriage of a dependent child, or a schoolchild no longer attending school, and • Due to the addition of removals to this application, VA has determined that the burden estimate has been increased from 15 to 30 minutes.

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Authorizing Statute(s): US Code: 38 USC 501(a) Name of Law: Rules and Regulations
   US Code: 38 USC 1115 Name of Law: Additional Compensation for Dependents
  

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:
	83 FR 3333	02/20/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 12329	06/08/2018
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
Application Request to Add and/or Remove Dependents (VA Form 21-686c)	21-686c	Application Request to Add and/or Remove Dependents

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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	226,000	226,000	0	0	0	0
Annual Time Burden (Hours)	113,000	56,500	0	56,500	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 burden increase is due to adding sections to the form for the removal of a dependent. The time to complete the form has increased from 15 minutes to 30 to accommodate this change.

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Annual Cost to Federal Government: $9,846,544

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

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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: 08/01/2018

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