Supporting Statement for 2900-0736 (08 29 13)

Supporting Statement for VA Form 21-0845

Authorization to Disclose Personal Beneficiary/Claimant

Information to a Third Party

2900-0736

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 5 U.S.C. 552a and 38 U.S.C. 5701 as implemented by 38 CFR 1.526(a) and 38 CFR 1.576(b).

2. VA Form 21-0845 will be used to release information in its custody or control in the following circumstances: where the individual identifies the particular information and consents to its use; for the purpose for which it was collected or a consistent purpose (i.e., a purpose which the individual might have reasonably expected). By law, VA must have a claimants or beneficiary’s written permission (an "authorization") to use or give out claim or benefit information for any purpose that is not contained in VA’s System of Records, 58VA21/22/28 Compensation, Pension, Education and Vocational Rehabilitation and Employment Records. The claimant or beneficiary may revoke the authorization at any time, except if VA has already acted based on the claimant’s permission.

3. VA Form 21-0845 will be 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 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.

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. The VA compensation and pension programs require that statements submitted by or on behalf of a claimant contain certification by the respondent that the information provided is true and correct. This form is designed to facilitate claims processing by providing a uniform format for the certification statement.

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 February 26, 2013, Volume 78, Number 38, on pages 13158-13159. 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 “Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 on June 19, 2009, and last amended at 77 FR 42593 (July 19, 2012).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 20,000 per year.

b. Frequency of Response is on occasion for most beneficiaries.

c. Annual burden is 1,667 hours.

d. The estimated completion time of 5 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $25,005 (1,667 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 $735,093

(GS-12/5 @ $40.66 x 20,000 x 15/60 minutes = $ 203,300)

(GS-9/5 @ $28.04 x 20,000 x 47/60 minutes = $439,293)

(GS-5/5 @ $18.50 x 20,000 x 15/60 minutes = $ 92,500)

b. Printing and production cost $1,800

c. Total cost to government $736,893

15. There is no change in the reporting burden. There is an increase in the cost to the government due to a printing cost error on the prior submission.

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

17. The collection instrument, VA Form 21-0845, 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 21-0845.

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

B. Collection of Information Employing Statistical Methods

The data collection does not employ statistical methods.