Statement in Support of Claim

ICR 199904-2900-005

OMB: 2900-0075

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
28222 Migrated
ICR Details
2900-0075 199904-2900-005
Historical Active 199508-2900-049
VA
Statement in Support of Claim
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 06/21/1999
Retrieve Notice of Action (NOA) 04/12/1999
Approved for use through 6/2002 under the condition that the VA immediately incorporates the new disclosure statements mandated by the Paperwork Reduction Act of 1995. For the public record, the VA must submit to OMB the revised forms/instructions.
  Inventory as of this Action Requested Previously Approved
06/30/2002 06/30/2002
752,000 0 0
188,000 0 0
0 0 0

VA form 21-4138 is used to provide self-certified statements in support of various types of claims processed by the Agency.

None
None


No

1
IC Title Form No. Form Name
Statement in Support of Claim 21-4138

  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 752,000 0 0 752,000 0 0
Annual Time Burden (Hours) 188,000 0 0 188,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$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.
04/12/1999


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