Supporting statement VAF 21-4165

Supporting Statement for VA Form 21-4165

Pension Claim Questionnaire for Farm Income

(2900-0095)

A. Justification

1. The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. A claimant’s eligibility for disability pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1541 and 1542, parents dependency and indemnity compensation under 38 U.S.C. 1315, and death compensation under 38 U.S.C. 1121 is determined, in part, by countable family income. Income information is requested by this form under the authority of 38 U.S.C. 1506. The regulatory basis is 38 C.F.R. 3.262 and 3.271.

2. VA Form 21-4165 is used to gather information which is necessary to determine the claimant’s countable annual income and available assets due to farm operations. Eligibility to income-based benefits cannot be determined without complete information about a claimant’s income. Farm income is not necessarily received on a weekly or monthly basis, and farm operating expenses must be considered in determining income and total assets.

3. VA Form 21-4165 is available on the One-VA Website in a fillable electronic format. Claimants may print and submit forms non-electronically. The Veterans Online Applications (VONAPP) allows applicants to view, print and submit applications electronically to VBA. However, since the estimated total usage of this form is low, it is not one of the forms scheduled to be added to VONAPP. The Department will reconsider adding this form to VONAPP when the resources become available or if usage of this form becomes greater.

4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.

5. The collection of information does not involve small businesses or entities.

6. The VA compensation and pension programs require current information to determine initial and continuing eligibility for benefits. Without the information provided on this form, VA would be unable to determine initial and continuing eligibility to pension benefits for claimants who have farm income, and benefits would not be properly paid.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in the Federal Register on August 22, 2007, Vol. 72, Number 162, page 47128. Outside consultations were not solicited as no major changes are being made to the form. Field stations have not reported any difficulty on the part of respondents in using the form. No comments were received.

9. No payments or gifts to respondents have been made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22, "Compensation, Pension, Education and Rehabilitation Records - VA" as set forth in Privacy Act Issuances, 1993 compilation found in 42 Fed. Reg. 49726 (9/27//1977).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 2,075 per year.

b. Frequency of Response is once a year for most beneficiaries.

c. Annual burden is 1,038 hours.

d. The estimated completion time of 30 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $15,570 (1,038 hours x $15 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $27,198

(GS-9/5 @ $25.00 x 1,038 x 55/60 minutes = $23,788)

(GS-3/5 @ $13.14 x 1,038 x 15/60 minutes = $ 3,410)

b. Printing and production cost $100

c. Total cost to government $27,298

15. There is no change in burden.

16. The information collection is not for publication or tabulation use.

17. The collection instrument, VA Form 21-4165, may be reproduced and/or stocked by the respondents and veterans service organizations. This VA form does not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of this form. This form is submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action on the benefit being sought. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA continues to seek an exemption that waives the displaying of the expiration date on VA Form 21-4165.

18. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

The Veterans Benefits Administration does not collect information employing statistical methods.