Eligibility Verification Reports

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0510 Eligibility Verification Report Instructions	Form	Modified	Available
Form VA Form 21-0518 Improved Pension Eligibility Report - Surviving Spouse With No Children	Form	Modified	Available
Form VA Form 21-0517 Improved Pension Eligibility Verification Report - Veteran With Children	Form	Modified	Available
Form VA Form 21-0516 Improved Pension Eligibility Report - Veteran With No Children	Form	Modified	Available
Form VA Form 21-0514 DIC Parent's Eligibility Verification Report	Form	Modified	Available
Form VA Form 21-0519s Improved Pension Eligibility Verification Report - Surviving Spouse With Children	Form	Modified	Available
Form VA Form 21-0519c Improved Pension Eligibility Report (Child or Children)	Form	Modified	Available
Form VA Form 21-0517-1 Improved Pension Eligibility Verification Report -Veteran With Children	Form	Modified	Available
Form VA Form 21-0519s-1 Improved Pension Eligibility Verification Report (Surviving Spouse with Children)	Form	Modified	Available
Form VA Form 21-0519c-1 Improved Pension Eligibility Verification Report (Child or Children)	Form	Modified	Available
Form VA Form 21-0518-1 Improved Pension Eligibility Verification Report (Surviving Spouse with No Children)	Form	Modified	Available
Form VA Form 21-0516-1 Improved Pension Eligibility Verification Report	Form	Modified	Available
Form VA Form 21-0514-1 DIC Parent's Eligibility Verification Report	Form	Modified	Available
Form VA Form 21-0513-1 Old Law and Section 306 Eligibility Verification Report (Children Only)	Form	Modified	Available
Form VA Form 21-0512v-1 Old Law and Section 306 Eligibility Verification Report (Veteran)	Form	Modified	Available
Form VA Form 21-0512s-1 Old Law and Section 306 Eligibility Verification Report (Surviving Spouse)	Form	Modified	Available
2900-0101 justification.docx	Supporting Statement A	Uploaded 2011-07-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28278	Eligibility Verification Reports	Form	Modified	Eligibility Verification Report Instructions
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Report - Surviving Spouse With No Children
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Verification Report - Veteran With Children
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Report - Veteran With No Children
28278	Eligibility Verification Reports	Form	Modified	DIC Parent's Eligibility Verification Report
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Verification Report - Surviving Spouse With Children
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Report (Child or Children)
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Verification Report -Veteran With Children
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Verification Report (Surviving Spouse with Children)
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Verification Report (Child or Children)
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Verification Report (Surviving Spouse with No Children)
28278	Eligibility Verification Reports	Form	Modified	Improved Pension Eligibility Verification Report
28278	Eligibility Verification Reports	Form	Modified	DIC Parent's Eligibility Verification Report
28278	Eligibility Verification Reports	Form	Modified	Old Law and Section 306 Eligibility Verification Report (Children Only)
28278	Eligibility Verification Reports	Form	Modified	Old Law and Section 306 Eligibility Verification Report (Veteran)
28278	Eligibility Verification Reports	Form	Modified	Old Law and Section 306 Eligibility Verification Report (Surviving Spouse)

ICR Details

OMB Control No: 2900-0101	ICR Reference No: 201104-2900-029
Status: Historical Active	Previous ICR Reference No: 200803-2900-012
Agency/Subagency: VA	Agency Tracking No: 2900-0101
Title: Eligibility Verification Reports
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/16/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/27/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved	01/31/2012
Responses	219,000	0	219,000
Time Burden (Hours)	113,075	0	113,075
Cost Burden (Dollars)	0	0	0

---

Abstract: The forms are used to determine and verify entitlement to income-based VA benefits. The forms are tailored for the specific classes of beneficiaries of each benefit program and request information about income, net worth, dependency status and other entitlement factors. Without this information, VA would be unable to properly pay benefits.

---

Authorizing Statute(s): US Code: 38 USC 1315 Name of Law: Dependency and indemnity compensation to parents
   US Code: 38 USC 1506 Name of Law: Resource reports and overpayment adjustments
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 91	05/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 141	07/22/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Eligibility Verification Reports	VA Form 21-0513-1, VA Form 21-0512s-1, VA Form 21-0514-1, VA Form 21-0519s-1, VA Form 21-0517-1, VA Form 21-0519s, VA Form 21-0514, VA Form 21-0517, VA Form 21-0516, VA Form 21-0518, VA Form 21-0510, VA Form 21-0519c, VA Form 21-0516-1, VA Form 21-0518-1, VA Form 21-0519c-1, VA Form 21-0512v-1	Old Law and Section 306 Eligibility Verification Report (Surviving Spouse) ,   Old Law and Section 306 Eligibility Verification Report (Veteran) ,   Old Law and Section 306 Eligibility Verification Report (Children Only) ,   DIC Parent's Eligibility Verification Report ,   Improved Pension Eligibility Verification Report ,   Improved Pension Eligibility Verification Report (Surviving Spouse with No Children) ,   Improved Pension Eligibility Verification Report (Child or Children) ,   Improved Pension Eligibility Verification Report (Surviving Spouse with Children) ,   Improved Pension Eligibility Verification Report -Veteran With Children ,   Improved Pension Eligibility Report (Child or Children) ,   Improved Pension Eligibility Verification Report - Surviving Spouse With Children ,   DIC Parent's Eligibility Verification Report ,   Improved Pension Eligibility Report - Veteran With No Children ,   Improved Pension Eligibility Verification Report - Veteran With Children ,   Improved Pension Eligibility Report - Surviving Spouse With No Children ,   Eligibility Verification Report Instructions

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	219,000	219,000	0	0	0	0
Annual Time Burden (Hours)	113,075	113,075	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $3,555,672

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/27/2011

---