2900-0067-SupportingStmt (02-2014)

Supporting Statement for VA Form 21-4502

Application for Automobile or Other Conveyance and

Adaptive Equipment (Under 38 U.S.C. 3901-3904)

(2900-0067)

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 survivors. Information is requested by this form under the authority of 38 U.S.C. 3901-3904 which provides eligibility to an automobile or other conveyance and adaptive equipment if the eligible person meets the disability requirements. On December 10, 2004, 38 U.S.C. 1151 was amended to extend eligibility to veterans receiving compensation for qualifying disabilities due to VA treatment or vocational rehabilitation. Regulatory authority is found in 38 CFR 3.808.

2. VA Form 21-4502 is used to gather the necessary information to determine if a veteran or serviceperson is entitled to an automobile allowance and adaptive equipment.

3. VA Form 21-4502 is 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. Veterans Online Applications (VONAPP) allows applicants to view, print, and submit applications electronically to VBA. However, VA Form 21-4502 is not one of the forms currently scheduled to be added to VONAPP because estimated total usage of this form is low. The Department will reconsider adding this form to VONAPP when the resources become available or if usage of this form becomes greater.

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. VA Form 21-4502 is used by veterans and servicepersons to apply for automobile and adaptive equipment benefits. Without the information solicited by this form, VA would be unable to determine eligibility, and benefits would not be properly paid.

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 XXXXX, page XXXXX.

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 75 FR 22187 (April 27, 2010).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 1,552 per year.

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

c. Annual burden is 388 hours.

d. The estimated completion time of 15 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $9,312 (388 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 $63,650

(GS-12/5 @ $40.66 x 1,552 x 5/60 minutes = $ 5,259)

(GS- 9/5 @ $28.04 x 1,552 x 70/60 minutes = $50,771)

(GS- 3/5 @ $14.73 x 1,552 x 20/60 minutes = $ 7,620)

b. Printing and production cost ($90 per thousand) $140

c. Total cost to government $63,790

15. The reporting burden has not changed even with the Notice of Proposed Rulemaking (NPRM) RIN 2900-AO81, “Standard Claims and Appeals Forms” which proposes to require all claims for benefits to be submitted on an application or form prescribed by the Secretary. However, the estimated costs to the federal government have been revised to reflect updated data. The form includes an expiration date placeholder per OMB’s guidance.

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.

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

B. Collection of Information Employing Statistical Methods

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