Information Collection

Pension Claim Questionnaire for Farm Income

IC 28263 under ICR 200707-2900-029 · OMB 2900-0095.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0095 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-4165 Pension Claim Questionnaire for Farm Income	Form
VA Form 21-4165 Pension Claim Questionnaire for Farm Income 21-4165.pdf www.va.gov/vaforms	Form

IC Title:

Pension Claim Questionnaire for Farm Income

Agency IC Tracking Number:

2900-0095

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.262 38 CFR 3.271

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-4165	Pension Claim Questionnaire for Farm Income	21-4165.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,075

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,075	2,075
Annual IC Time Burden (Hours)	1,038	1,038
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.