2900-0115 justification

Supporting Statement for VA Form 21-4171

Supporting Statement Regarding Marriage

(2900-0115)

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. Information is requested by this form under the authority of 38 U.S.C. 103 which requires that a marital relationship be established before benefits may be paid to or for a spouse of a veteran.

2. VA Form 21-4171 is used to gather the necessary information from individuals who know, as the result of personal observation, the relationship which existed between the veteran and claimed spouse, when common law marriage is claimed. This information is necessary to determine if a marital relationship is established and benefits are payable based on the marital relationship.

3. VA Form 21-4171 is available on the One-VA web site in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the forms to be incorporated with an existing centralized legacy database. Veterans Online Applications (VONAPP) allows applicants to view, print, and submit applications electronically to VBA. However, VA Form 21-4171 is not one of the forms to be added to VONAPP because estimated total usage of this form is minimal. 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. VA Form 21-4171 requests information needed to determine eligibility to benefits based on marital relationship. Without this information, an accurate determination of a common law marital relationship would not be made, 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 January 22, 208, Volume 73, Number 14, pages 808-3809. 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 2,400 per year.

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

c. Annual burden is 800 hours.

d. The estimated completion time of 20 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $12,000 (800 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 $48,154

(GS-9/5 @ $25.00 x 2,400 x 45/60 minutes = $45,000)

(GS-3/5 @ $13.14 x 2,400 x 6/60 minutes = $ 3,154)

b. Printing and production cost $160

c. Total cost to government $48,314

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 21-4171, 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 21-4171.

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.