Ss-vaf 21-4193

Supporting Statement for VA Form 21-4193

Notice to Department of Veterans Afffairs of Veteran

or Beneficiary Incarcerated in Penal Institution

(2900-0116)

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. 38 U.S.C. 1505 and 5313 require reduction or termination of a beneficiary's VA compensation or pension rate when the beneficiary is incarcerated in a penal institution in excess of 60 days after conviction.

2. VA Form 21-4193 is used by penal institutions to provide information to VA regional offices about incarcerated VA beneficiaries.

3. The collection of information does not involve the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology. VA Form 21-4193 is partially completed by VA with beneficiary-specific information before it is mailed to penal institutions. To avoid improper use by claimants who are not required to submit this form, the form is not available on the VBA website for downloading. A faxed copy of a properly signed VA Form 21-4193 may be accepted if there are no questions as to its validity. Currently, there has been no consideration of using other information technology. The Department will reconsider using other information technology when the resources become available, and usage of this form increases.

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. If the collection were not conducted, VA would not have the information needed to accurately adjust the VA rates of incarcerated beneficiaries. Benefits would not be properly paid, and overpayments would result.

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 October 1, 2007, volume 72, Number 189, page 55859. 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 1,664 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 416 hours.

d. The estimated completion time of 15 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $6,240 (416 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 $54,710

(GS-12/5 @ $36.26 x 1,664 x 15/60 minutes = $15,084)

(GS-9/5 @ $25.00 x 1,664 x 54/60 minutes = $37,440)

(GS-3/5 @ $13.14 x 1,664 x 6/60 minutes = $ 2,186)

b. Printing and production cost ($25/thousand) $50

c. Total cost to government $54,760

15. There is no change in the reporting burden.

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 The information collection is not for publication or tabulation use.

17. The collection instrument, VA Form 21-4193, 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 21-4193.

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

B. Collection of Information Employing Statistical Methods

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