Claim for Disability Insurance Benefits, Government Life Insurance

Forms and Documents

Document Name	Status
Form 29-357 Claim for Disability Insurance Benefits, Government Life Insurance Form	Modified
VBA-29-357-ARE.pdf Supplementary Document	2012-05-03
2900-0016 justification.docx Supporting Statement A	2011-11-14

IC Document Collections

IC ID	Document Title	Status
28103	Claim for Disability Insurance Benefits, Government Life Insurance Form	Modified

ICR Details

OMB Control No: 2900-0016	ICR Reference No: 201108-2900-014
Status: Historical Active	Previous ICR Reference No: 200806-2900-003
Agency/Subagency: VA	Agency Tracking No: 2900-0016
Title: Claim for Disability Insurance Benefits, Government Life Insurance
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 with change	Conclusion Date: 06/12/2012
	Date Received in OIRA: 12/09/2011
Terms of Clearance: Approved consistent with revised form submitted to OMB by VA and included in the public docket on 5/3/2012.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved	06/30/2012
Responses	8,100	0	8,100
Time Burden (Hours)	14,175	0	14,175
Cost Burden (Dollars)	0	0	0

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Abstract: This form is designed for use by the insurance activity to determine the insured's eligibility for disability insurance benefits. The information is authorized by law, USC Sections 1912, 1915, 1942, 1948.

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Authorizing Statute(s): US Code: 38 USC 1948 Name of Law: Total Disability Provision
   US Code: 38 USC 1915 Name of Law: Total Disability Income Provision
   US Code: 38 USC 1942 Name of Law: Plans of Insurance
   US Code: 38 USC 1912 Name of Law: Total Disability Waiver
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 177	08/13/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 223	11/18/2011
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Claim for Disability Insurance Benefits, Government Life Insurance	29-357	Claim for Disability Insurance Benefits

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ICR Summary 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	8,100	8,100	0	0	0	0
Annual Time Burden (Hours)	14,175	14,175	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:

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Annual Cost to Federal Government: $68,972

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

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Common Form ICR:  No

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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: 12/09/2011

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