Income and Asset Statement in Support of Claim for Pension or Parents' DIC (VA Form 21P-0969)

Forms and Documents

Document Name	Status
Form 21P-0969 Income and Asset Statement in Support of Claim for Pension or Parents' DIC (VA Form 21P-0969) Form and Instruction	Modified
FRN Correction Notice (2900-0829) 9-15-23.docx Supplementary Document	2023-10-04
30-Day FRN - 2900-0829 (2023) 2.pdf Supplementary Document	2023-10-04
OMB 2900-0829 Withdrawn 30-day FRN (9-29-23).pdf Supplementary Document	2023-09-29
60-Day FRN Published (2900-0829, 0969).pdf Supplementary Document	2023-09-18
2900-0829, SS (VAF 21P-0969), 20231004.docx Supporting Statement A	2023-10-04

IC Document Collections

IC ID	Document Title	Status
214403	Income and Asset Statement in Support of Claim for Pension or Parents' DIC (VA Form 21P-0969) Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0829	ICR Reference No: 202309-2900-002
Status: Received in OIRA	Previous ICR Reference No: 202108-2900-017
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-YA
Title: Income and Asset Statement in Support of Claim for Pension or Parents' DIC (VA Form 21P-0969)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/04/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2024
Responses	55,000	75,000
Time Burden (Hours)	22,917	31,250
Cost Burden (Dollars)	0	0

---

Abstract: VA Form 21P-0969 will be used by claimants for VA Pension or Parents' Dependency and Indemnity Compensation (DIC) to provide information pertaining to income and assets to establish entitlement to Pension or Parents' DIC. This form will be completed only by those claimants who had income other than Social Security benefits during the calendar year before claiming benefits or who disposed of assets or have significant assets which may affect their entitlement to needs-based benefits.

---

Authorizing Statute(s): US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income
   US Code: 38 USC 1315 Name of Law: Dependency and indemnity compensation to parents
   US Code: 38 USC 1543 Name of Law: Net worth limitation
  

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:
	88 FR 43171	07/06/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 68906	10/04/2023
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
Income and Asset Statement in Support of Claim for Pension or Parents' DIC (VA Form 21P-0969)	21P-0969	Income and Asset Statement in Support of Claim for Pension or Parent's Dependency and Indemnity Compensation (D.I.C.)

---

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	55,000	75,000	0	-20,000	0	0
Annual Time Burden (Hours)	22,917	31,250	0	-8,333	0	0
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: Burden reduction is due to the reduction of actual receipts of the form.

---

Annual Cost to Federal Government: $1,511,253

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

---

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: 10/04/2023

---