OMB29-4364,c&0151(3-6-14)

SUPPORTING STATEMENT FOR

VA FORM 29-4364, VA FORM 29-4364C & VA FORM 29-0151,

APPLICATION FOR SERVICE

DISABLED INSURANCE

2900-0068

A. JUSTIFICATION:

1. These forms are used by veterans to apply for Service Disabled Veterans Insurance, to designate a beneficiary and to select an optional settlement. The information is required by law, 38 USC, Section 1922.

The 30-day FRN indicated this was an extension, however the minor revision to the form makes it a revision. . The expiration date is being added to the form.

2. The data collected on these forms are used by Department of Veterans Affairs (VA) to determine the veteran’s eligibility for insurance.

3. VA Form 29-4364 is available on the One-VA web site in a fillable electronic format and the VA Insurance website. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. VA Form 29-0151 is released to the veteran when he/she is first notified of their disability rating. This form is not available to the general public. VA Form 29-4364C also is not available to the general public. The Department of Veterans Affairs will release this form to the appropriate individuals. 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. The information is not contained in any other VA records. Similar information is not available elsewhere.

5. The information does not involve any small businesses.

6. These forms are designed for use by the insured to apply for Service Disabled Veterans Insurance, to designate a beneficiary and to select an optional settlement.

7. There are no special circumstances requiring that the collection of information be conducted in a manner inconsistent with the guidelines in 5 CFR Section 1320.6.

8. The Department notice was published in the Federal Register on November 20, 2013, Volume 78, No. 224, pages 69747-69748. No comments were received in response to this notice.

9. The information collected is supplied by the respondent. No remuneration is made.

10. The information collection conforms with the Privacy Act of 1974 and is subject to the conditions of disclosure contained therein. The records are maintained in the system identified as 36VA00, “Veterans and Armed Forces Personnel United States Government Life Insurance Records - VA” as contained in the Privacy Act Issuances, 1993 Compilation.

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden

We arrived at this estimate by initiating a trial with a VA staff member unfamiliar with the forms.

a. Number of Respondents: 25,000

b. Frequency of Response: Once

c. Annual Burden Hours: 8,333

d. Estimated Completion Time: 20 minutes

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 $199,992. (8,333 burden hours X $24 per hour).

13. This submission does not involve any record keeping costs.

14. Cost to Government:

$12,925.00 Estimated mailing cost (25,000 X 2 minutes per

form X $15.51/hour (average salary for station

mail personnel)

$11,650.00 Estimated cost for collections (25,000 X 2 minutes

per X $13.98/hour (average salary of station collections

personnel)).

$991,500.00 Estimated cost for processing (25,000 forms X 120

minutes per form X $19.83/hour (average salary

for reviewers)).

$750.00 Estimated printing costs (25,000 X $30/1,000 forms).

$1,016,825.00 Total cost to the Government.

15. There is no change in respondent burden. The expiration date is being added to the forms.

16. The information is collected for insurance purposes only and there are no plans for publication.

17. We are not seeking approval to omit the expiration date for OMB approval.

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

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS:

The Veterans Benefits Administration does not collect information employing statistical methods.