Supporting Statement for VA Form 21-4193
Notice to Department of Veterans Afffairs of Veteran
or Beneficiary Incarcerated in Penal Institution
(2900-0116)
A. Justification
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 U.S.C. 1505 and 5313 require reduction or termination of a beneficiary's VA compensation or pension rate when the beneficiary is incarcerated in a penal institution in excess of 60 days after conviction. The 30-day FRN indicated this was an extension. However, after adding the expiration date placeholder, it is now a revision.
2. VA Form 21-4193 is used by penal institutions to provide information to VA regional offices about incarcerated VA beneficiaries.
3. The collection of information does not involve the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology. VA Form 21-4193 is partially completed by VA with beneficiary-specific information before it is mailed to penal institutions. To avoid improper use by claimants who are not required to submit this form, the form is not available on the VBA website for downloading. A faxed copy of a properly signed VA Form 21-4193 may be accepted if there are no questions as to its validity. Currently, there has been no consideration of using other information technology. The Department will reconsider using other information technology when the resources become available, and usage of this form increases.
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. If the collection were not conducted, VA would not have the information needed to accurately adjust the VA rates of incarcerated beneficiaries. Benefits would not be properly paid, and overpayments would result.
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, Number 79, Volume 21, on January 31, 2014, pages 5529 and 5530. Field stations have not reported any difficulty on the part of respondents in using the form. No comments were received.
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 1,664 per year.
b. Frequency of Response is one time for most beneficiaries.
c. Annual burden is 416 hours.
d. The estimated completion time of 15 minutes is based on review by staff personnel and previous usage of this form.
e. According to the U.S. Bureau of Labor Statistics Average Hourly Earnings, the cost to the respondent is $24, making the total cost to the respondents an estimated $9,984 (416 burden hours x $24 per hour).
13. This submission does not involve any recordkeeping costs.
14. Estimated Costs to the Federal Government:
a. Processing/Analyzing costs $61,359
(GS-12/5 @ $40.66 x 1,664 x 15/60 minutes = $16,915)
(GS-9/5 @ $28.04 x 1,664 x 54/60 minutes = $41,993)
(GS-3/5 @ $14.73 x 1,664 x 6/60 minutes = $ 2,451)
b. Printing and production cost ($90/thousand) $5,490
c. Total cost to government $66,849
There is no change in the reporting burden. The expration date is being added to the form.
16. The information collection is not for publication or tabulation use.
17. We are not seeking approval to omit the expiration date for OMB approval.
This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
1. The Veterans Benefits Administration does not collect information employing statistical methods.
| File Type | application/msword |
| File Title | SF 83 SS VAF 21-8926 |
| Author | Veterans Benefits Administrat |
| Last Modified By | McCargo, Yvette, VBAVACO |
| File Modified | 2014-03-21 |
| File Created | 2014-03-21 |