Statement in Support of Claim (VA Form 21-4138)

Forms and Documents

Document Name	Status
Form 21-4138 Statement in Support of Claim (VA Form 21-4138) Form	Modified
2021-09918, 30-Day FRN (VAF21-4138).pdf Supplementary Document	2021-05-11
2021-02481, 60-Day FRN (VAF21-4138).pdf Supplementary Document	2021-02-19
2900-0075, Supporting Statement (VAF 21-4138).docx Supporting Statement A	2021-05-05

IC Document Collections

IC ID	Document Title	Status
28224	Statement in Support of Claim (VA Form 21-4138) Form	Modified

ICR Details

OMB Control No: 2900-0075	ICR Reference No: 202009-2900-018
Status: Received in OIRA	Previous ICR Reference No: 201709-2900-013
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-MS
Title: Statement in Support of Claim (VA Form 21-4138)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/11/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	486,174	0
Time Burden (Hours)	121,544	0
Cost Burden (Dollars)	0	0

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Abstract: VA Form 21-4138 is used to provide self-certified statements in support of various types of claims processed by VA. Statements submitted by or on behalf of a claimant should contain certification by the respondent that the information provided is true and correct. This form facilitates claims processing by providing a uniform format for the certification statement.

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Authorizing Statute(s): US Code: 38 USC 501 Name of Law: Rules and regulations
  

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:
	86 FR 8682	02/08/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 25938	05/11/2021
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
Statement in Support of Claim (VA Form 21-4138)	21-4138	Statement in Support of Claim

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ICR Summary of Burden

	Total Request	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	486,174	0	0	-265,826	0	752,000
Annual Time Burden (Hours)	121,544	0	0	-66,456	0	188,000
Annual Cost Burden (Dollars)	0	0	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Due to a reduction in respondent totals over the past year, the respondent burden has decreased.

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Annual Cost to Federal Government: $8,998,297

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? No

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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: 05/11/2021

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