Information Collection

Request for Nursing Home Information in Connection with Claim for Aid and Attendance

IC 28927 under ICR 200708-2900-012 · OMB 2900-0652.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0652 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance	Form
VA Form 21-0779 Request for Nursing Home Information in Connection with 21-0779.pdf www.va.gov/vaforms	Form

IC Title:

Request for Nursing Home Information in Connection with Claim for Aid and Attendance

Agency IC Tracking Number:

2900-0652

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 3.551 38 CFR 3.351

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 21-0779	Request for Nursing Home Information in Connection with Claim for Aid and Attendance	21-0779.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: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	8,333	8,333
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.