Statement of Marital Relationship

ICR 200503-2900-015

OMB: 2900-0114

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
28314 Migrated
ICR Details
2900-0114 200503-2900-015
Historical Active 200202-2900-011
VA
Statement of Marital Relationship
Revision of a currently approved collection   No
Regular
Approved with change 06/03/2005
Retrieve Notice of Action (NOA) 03/17/2005
Approved consistent with clarification in VA memo submitted to OMB 06/02/05.
  Inventory as of this Action Requested Previously Approved
06/30/2008 06/30/2008 06/30/2005
6,500 0 6,000
2,708 0 3,000
0 0 0

VA Form 21-4170 is used to gather information that is necessary to determine whether a valid common law marriage was established. The form is used b persons claiming to be common law surviving spouses of deceased veterans and by veterans and their claimed common law spouses. Benefits cannot be authorized unless a valid marriage is established.

None
None


No

1
IC Title Form No. Form Name
Statement of Marital Relationship 21-4170

  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 6,500 6,000 0 0 500 0
Annual Time Burden (Hours) 2,708 3,000 0 0 -292 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
03/17/2005


© 2024 OMB.report | Privacy Policy