STATEMENT OF APPLICANT AND /OR PHYSICAL EXAMINATION REPORT

ICR 198406-2900-016

OMB: 2900-0087

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
2900-0087 198406-2900-016
Historical Active 198104-2900-016
VA
STATEMENT OF APPLICANT AND /OR PHYSICAL EXAMINATION REPORT
Revision of a currently approved collection   No
Regular
Approved without change 08/15/1984
Retrieve Notice of Action (NOA) 06/19/1984
  Inventory as of this Action Requested Previously Approved
06/30/1987 06/30/1987 06/30/1984
1,400 0 2,500
1,820 0 3,250
0 0 0

THIS FORM IS USED TO REQUEST SUPPLEMENTAL MEDICAL INFORMATION IN CONJUNCTION WITH AN APPLICATION FOR INSURANCE. THE INFORMATION ON THE FORM IS REQUIRED BY LAW, 38 USC SECTIONS 715, 742, 748 AND 781, 38 CFR SECTIONS 6.80, 8.24 AND 8.36.

None
None


No

1
IC Title Form No. Form Name
STATEMENT OF APPLICANT AND /OR PHYSICAL EXAMINATION REPORT 29-4465

  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 1,400 2,500 0 -1,100 0 0
Annual Time Burden (Hours) 1,820 3,250 0 -1,430 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/19/1984


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