Information Collection

Income and Asset Statement in Support of Claim for

IC 214403 under ICR 201809-2900-003 · OMB 2900-0829.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0829 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21P-0969 Income and Asset Statement in Support of Claim for Form
VA Form 21P-0969 Income and Asset Statement in Support of Claim for Pensi 21P-0969(12-23-14).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Income and Asset Statement in Support of Claim for	Agency IC Tracking Number:	2900-0829

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.5 38 CFR 3.275 38 CFR 3.3

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21P-0969	Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC)	21P-0969(12-23-14).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)	FR Citation: 74 FR 29275

Number of Respondents: 60,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.