MARITAL STATUS QUESTIONNAIRE

ICR 199105-2900-001

OMB: 2900-0495

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
148320 Migrated
ICR Details
2900-0495 199105-2900-001
Historical Active 198807-2900-003
VA
MARITAL STATUS QUESTIONNAIRE
Revision of a currently approved collection   No
Regular
Approved without change 06/07/1991
Retrieve Notice of Action (NOA) 05/02/1991
  Inventory as of this Action Requested Previously Approved
06/30/1994 06/30/1994 06/30/1991
34,500 0 88,000
2,875 0 14,667
0 0 0

THIS VA FORM IS USED TO REQUEST CERTIFICATION OF A CONTINUED UNREMARRIED STATUS BY SURVIVING SPOUSES IN RECEIPT OF DEPENDENCY AND INDEMNITY COMPENSATION. THIS INFORMATION IS NECESSARY TO DETERMINE THEIR CONTINUED ELIGIBILITY TO SUCH BENEFITS.

None
None


No

1
IC Title Form No. Form Name
MARITAL STATUS QUESTIONNAIRE VA 21-0537

  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 34,500 88,000 0 -13,375 -40,125 0
Annual Time Burden (Hours) 2,875 14,667 0 -2,948 -8,844 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.
05/02/1991


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