2900-0734 justification

Supporting Statement for

VA Form 21-0820, Report of General Information

VA Form 21-0820a, Report of Death of Beneficiary

VA Form 21-0820b, Report of Nursing Home Information

VA Form 21-0820c, Report of Defense Finance and Accounting Service (DFAS)

VA Form 21-0820d, Report of Lost Check

VA Form 21-0820e, Report of Incarceration

VA Form 21-0820f, Report of Month of Death

2900-0734

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 Code of Federal Regulations 3.217 provides that action affecting entitlement to benefits may be taken based on oral information or statements provided to VA by a beneficiary or his or her fiduciary.

2. VA Form 21-0820, 21-0820a, 21-0820b, 21-0820c, 21-0820d, 21-0820e, and 21-0820f will be used to document the information received orally and that the VA employee receiving the information meets the series of conditions necessary to enable VA to take action based on information received orally. Without this information action can not be taken on any information received orally.

3. VA Form 21-0820, 21-0820a, 21-0820b, 21-0820c, 21-0820d, 21-0820e, and 21-0820f are are available on the One-VA web site in a fillable electronic format and VBA’s Virtual VA application. VBA maintains a secure server for forms of this type, but 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 form to be incorporated with an existing centralized legacy database.

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. This form is designed in a “user friendly” format, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing.

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 April 18, 2012, at page 23322. There were no comments received in response to this notice.

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 58VA21/22/28,‘‘Compensation, Pension, Education, and Rehabilitation Records—VA ’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 2,550,000 per year for all forms:

1. VA Form 21-0820: 2,360,000

2. VA Form 21-0820a: 80,000

3. VA Form 21-0820b: 30,000

4. VA Form 21-0820c: 30,000

5. VA Form 21-0820d: 30,000

6. VA Form 21-0820e: 10,000

7. VA Form 21-0820f: 10,000

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

c. Annual burden is 212,500 hours.

8. VA Form 21-0820: 196,667

9. VA Form 21-0820a: 6,667

10. VA Form 21-0820b: 2,500

11. VA Form 21-0820c: 2,500

12. VA Form 21-0820d: 2,500

13. VA Form 21-0820e: 833

14. VA Form 21-0820f: 833

d. The estimated completion time of 5 minutes per form is based on review by staff personnel.

e. The total estimated cost to respondents is $3,187,500 (212,500 hours x $15/hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $10,829,000

VA Form 21-0820

(GS- 9/5 @ $28.04 x 2,360,000 x 5/60 minutes = $5,514,533.33)

(GS- 7/5 @ $22.92 x 2,360,000 x 5/60 minutes = $4,507,600.00)

Total: $10,022,133.33

VA Form 21-0820a

(GS- 9/5 @ $28.04 x 80,000 x 5/60 minutes = $186,933.33)

(GS- 7/5 @ $22.92 x 80,000 x 5/60 minutes = $152,800.00)

Total: $339,733.33

VA Form 21-0820b

(GS- 9/5 @ $28.04 x 30,000 x 5/60 minutes = $70,100.00)

(GS- 7/5 @ $22.92 x 30,000 x 5/60 minutes = $57,300.00)

Total: $127,400.00

VA Form 21-0820c

(GS- 9/5 @ $28.04 x 30,000 x 5/60 minutes = $70,100.00)

(GS- 7/5 @ $22.92 x 30,000 x 5/60 minutes = $57,300.00)

Total: $127,400.00

VA Form 21-0820d

(GS- 9/5 @ $28.04 x 30,000 x 5/60 minutes = $70,100.00)

(GS- 7/5 @ $22.92 x 30,000 x 5/60 minutes = $57,300.00)

Total: $127,400.00

VA Form 21-0820e

(GS- 9/5 @ $28.04 x 10,000 x 5/60 minutes = $23,366.67)

(GS- 7/5 @ $22.92 x 10,000 x 5/60 minutes = $19,100,.00)

Total: $42,466.67

VA Form 21-0820f

(GS- 9/5 @ $28.04 x 10,000 x 5/60 minutes = $23,366.67)

(GS- 7/5 @ $22.92 x 10,000 x 5/60 minutes = $19,100,.00)

Total: $42,466.67

b. Printing and production cost $284

c. Total cost to government $10,829,284

15. Burden increase due to typo in initial entry.

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

17. Please reference all of the forms in this statement. The collection instruments, VA Form 21-0820, 21-0820a, 21-0820b, 21-0820c, 21-0820d, 21-0820e, and 21-0820f 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. These forms will be 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. 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 seeks an exemption that waives the displaying of the expiration date on VA Form 21-0820, 21-0820a, 21-0820b, 21-0820c, 21-0820d, and 21-0820e.

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

B. Collection of Information Employing Statistical Methods

This data collection does not employe statistical methods.