Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0820f Report of Contact - Month of Death Claim	Form	Modified	Available
Form VA Form 21-0820e Report of Incarceration	Form	Modified	Available
Form VA Form 21-0820d Report of Non-Receipt of Payment	Form	Modified	Available
Form VA Form 21-0820c Report of Defense Finance & Accounting Service (DFAS)	Form	Modified	Available
Form VA Form 21-0820b Report of Nursing Home or Assisted Living Information	Form	Modified	Available
Form VA Form 21-0820a Report of Death of Veteran/Beneficiary	Form	Modified	Available
Form VA Form 21-0820 Report of General Information	Form	Modified	Available
2900-0734 justification.docx	Supporting Statement A	Uploaded 2012-06-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
187592	Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	Form	Modified	Report of Contact - Month of Death Claim
187592	Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	Form	Modified	Report of Incarceration
187592	Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	Form	Modified	Report of Non-Receipt of Payment
187592	Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	Form	Modified	Report of Defense Finance & Accounting Service (DFAS)
187592	Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	Form	Modified	Report of Nursing Home or Assisted Living Information
187592	Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	Form	Modified	Report of Death of Veteran/Beneficiary
187592	Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	Form	Modified	Report of General Information

ICR Details

OMB Control No: 2900-0734	ICR Reference No: 201203-2900-019
Status: Historical Active	Previous ICR Reference No: 200812-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0734
Title: Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check
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: 08/31/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/06/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved	08/31/2012
Responses	2,550,000	0	2,550,000
Time Burden (Hours)	212,500	0	35,501
Cost Burden (Dollars)	0	0	0

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Abstract: These forms will be used by VA Regional Office and Pension Maintenance Center employees to meet our requirement to document verbal evidence obtained telephonically from our beneficiary or claimant that will be used as part of the evidence for a claim for benefits.

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Authorizing Statute(s): None

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:
	77 FR 75	04/18/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 124	06/27/2012
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Report of General Info., Rpt of Death of Veteran/Beneficiary, Rpt of Nursing Home Info., Rpt of Defense Finance & Accounting Service, Rpt of Lost Check, Report of Incarceration, Month of Death Check	VA Form 21-0820e, VA Form 21-0820a, VA Form 21-0820b, VA Form 21-0820f, VA Form 21-0820d, VA Form 21-0820c, VA Form 21-0820	Report of General Information ,   Report of Death of Veteran/Beneficiary ,   Report of Nursing Home or Assisted Living Information ,   Report of Defense Finance & Accounting Service (DFAS) ,   Report of Non-Receipt of Payment ,   Report of Incarceration ,   Report of Contact - Month of Death Claim

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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	2,550,000	2,550,000	0	0	0	0
Annual Time Burden (Hours)	212,500	35,501	0	0	176,999	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: Burden increase due to typo in initial entry.

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Annual Cost to Federal Government: $10,829,284

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: 07/06/2012

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