Statement in Support of Claim

ICR 200506-2900-002

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
28224 Migrated
ICR Details
2900-0075 200506-2900-002
Historical Active 200204-2900-006
VA
Statement in Support of Claim
Extension without change of a currently approved collection   No
Regular
Approved with change 08/22/2005
Retrieve Notice of Action (NOA) 06/07/2005
Approved consistent with the following terms of clearance: in the next submission of this collection of information VA shall report to OMB on the status of offering users fully integrated electronic versions of forms associated with this collection which may be completed and submitted online in compliance with the Government Paperwork Elimination Act of 1998.
  Inventory as of this Action Requested Previously Approved
08/31/2008 08/31/2008 08/31/2005
752,000 0 752,000
188,000 0 188,000
0 0 0

VA Form 21-4138 is used to provide self-certified statements in support of various types of claims processed by VA. Statements submitted by or on behalf of a claimant should contain certification by the respondent that the information provided is true and correct. This form facilitates claims processing by providing a uniform format for the certification statement.

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 752,000 752,000 0 0 0 0
Annual Time Burden (Hours) 188,000 188,000 0 0 0 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.
06/07/2005


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