2900-0001 -SuppStmt (6-19-14) OIRA

Supporting Statement for:

(2900-0001)

VA Form 21-526	Veteran’s Application for Compensation and/or Pension
VA Form 21-526b	Veteran’s Supplemental Claim Application
VA Form 21-4142a	General Release for Medical Provider Information to the Department of Veterans Affairs (VA)
VA Form 21-4142	Authorization and Consent to Release Information to the Department of Veterans Affairs

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. Title 38 U.S.C. 5101(a) provides that a specific claim in the form provided by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by the Secretary. VA Form 21-526 is the prescribed form for initial disability claims. VA Form 21-526b is the prescribed form for supplemental disability or ancillary benefit claims. VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather private provider information of the Veteran to VA.

VA is redesigning the current VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), Feb 2012. VA is revising VA Form 21-4142 to be compliant with Health and Human Services and Social Security Administration forms. Instead of requiring a signed form from the claimant for each Private Health Provider (PHP), the claimant only has to give VA this general consent to go out for these records. The consent was also increased from six months to one year. VA is also redesigning the form for clarity and ease of use.

In the redesign of VA Form 21-4142, the PHP information is not gathered anywhere else in the application process thus increasing the burden on VA to develop for this information. The new VA Form 21-4142a is created to gather PHP information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.

2. VA Form 21-526 and 21-526b are used to gather the necessary information to determine a Veteran’s eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible.

VA has updated the direct deposit information on the VA Form 21-526 to comply with Department of Treasury requirements.

VA added a field to the 21-526 requesting information on a claimant’s transferred assets based on VA Office of General Counsel experience:

• VA has seen a lot of activity from attorneys practicing elder law, who, in some cases, claim that they can assist individuals in qualifying for VA aid and attendance by transferring their assets using various types of trust instruments.  VA must generally consider such assets in determining eligibility unless the applicant relinquished all ownership and control.  We have communicated with a few individuals regarding their promotional material, which implies that prior to applying for pension the claimant may transfer assets and that there is no need to inform VA of the transfer.  This presents a problem because attorneys may advise claimants to transfer their assets, charge a fee for the transfer, and assist the claimant in preparing a pension claim.  A few years later, when VA learns of the transferred assets, which the claimant continued to control, VA creates a debt that the beneficiary may not be able to repay.  Family members then request a waiver.  This has actually happened in a few cases.

In response to the above statement, Part IX, paragraph 4, of VA Form 21-526 instructions are being revised to state the following:

• You must disclose all financial transactions that involve a transfer of assets that occurred within the last three years, even if the transaction occurred prior to the date of your application for VA pension.  A gift of property or a sale below the property’s value to a relative residing in the same household does not reduce net worth.  Likewise, a gift of property to someone other than a relative residing in your household does not reduce net worth unless it is clear that you have relinquished all rights of ownership, including the right to control the property.  Send in a separate sheet of paper listing all asset transfers, including the date and type of transfer.

Additionally, claimants who need assistance in obtaining non-VA medical records complete VA Form 21-4142. VA is revising the VA Form 21-4142 to be compliant with Health and Human Services and Social Security Administration forms. Instead of requiring a signed form from the claimant for each PHP, the claimant only has to give VA this general consent to go out for these records. The consent was also increased from six months to one year.

However, in the redesign of the VA Form 21-4142, the PHP information is not gathered anywhere else in the application process thus increasing the burden on VA to develop for this information. The new VA Form 21-4142a is created to gather PHP information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.

3. VA Forms 21-4142, 21-4142a, 21-526, and 21-526b is available on the One-VA Website in a fillable electronic format. 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. 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. These forms were redesigned into a “user friendly” form, 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 (60-day) was published in the Federal Register on:

• January 3, 2014, Vol. 79, No. 2, pages 424 and 425. No comments were received.

The Department notice (30-day) was published in the Federal Register on:

• March 20, 2014, Vol. 79, No. 54, page 15621.

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 (June 19, 2009).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

1. Number of yearly respondents totals = 724,108:

   1. 391,708 for VA Form 21-526,

   2. 200,000 for VA Form 21-526b

   3. 66,200 for VA Form 21-4142, and

   4. 66,200 for VA Form 21-4142a.

2. Frequency of Response is one time.

3. Annual burden total = 452,740:

   1. 391,708 for VA Form 21-526,

   2. 50,000 for VA Form 21-526b,

   3. 5,516 for VA Form 21-4142, and

   4. 5,516 for VA Form 21-4142a.

4. The estimated completion time is:

   1. 60 minutes for VA Form 21-526,

   2. 15 minutes for VA Form 21-526b,

   3. 5 minutes for VA Form 21-4142, and

   4. 5 minutes for VA Form 21-4142a.

5. 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 $10,865,760 (452,740 burden hours x $24 per hour).

13. VA recognizes there may be costs with 3^rd party assistance. VA requests input from the public.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $12,694,866

• (GS- 9/5 @ $28.04 x 391,708 x 60/60 minutes = $10,983,492)

• (GS- 9/5 @ $28.04 x 200,000 x 15/60 minutes = $1,402,000)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

b. Forms are available on the VA inter/intranet forms websites.

c. Printing and production cost ($90/thousand) $5,490

d. Total cost to government $12,700,356

15. Supplemental Statement for VA Form 21-4142:

VA is redesigning the current VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), Feb 2012. VA is revising the VA Form 21-4142 to be compliant with Health and Human Services and Social Security Administration forms. Instead of requiring a signed form from the claimant for each PHP, the claimant only has to give VA this general consent to go out for these records. The consent was also increased from six months to one year. VA is also redesigning the form for clarity and ease of use. This redesign does not increase the respondent burden.

Supplemental Statement for VA Form 21-4142a:

VA has newly created the VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). The new VA Form 21-4142a is created to gather PHP information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.

Supplemental Statement regarding non-substantive changes made to VA Forms 21-526 and 21-526b:

On June 26, 2013, the Supreme Court held, in United States v. Windsor, that section 3 of the Defense of Marriage Act (DOMA) violates the Fifth Amendment by discriminating against same-sex couples who are lawfully married under state law.

VBA administers benefits and programs that depend on the definition of the terms “spouse” and “surviving spouse.” For purposes of VA benefits, 38 U.S.C. § 101(3) and § 101(31) define “surviving spouse” and “spouse” as persons “of the opposite sex.” These definitions (codified separately from DOMA) were not specifically addressed in the Supreme Court’s decision. On September 4, 2013, the United States Attorney General announced that the President had directed the Executive Branch to cease enforcement of 38 U.S.C. §§ 101(3) and 101(31), to the extent they preclude provision of Veterans’ benefits to same-sex married couples. Accordingly, VA will no longer enforce the above-mentioned statutory provisions or VBA’s implementing regulation (38 C.F.R. § 3.50), to the extent that they preclude provision of Veterans’ benefits to same-sex married couples. This announcement allows VA to administer spousal and survivors’ benefits to same-sex married couples, provided their marriages meet the requirements of 38 U.S.C. § 103(c).

Therefore, VA is revising VA Form 21-527EZ, to add the following statute language approved by the White House and Department of Justice, in the instructions section of the form:

IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for benefits) (38 U.S.C. § 103(c)).  Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.

16. The change of the direct deposit information has no effect on the respondent burden as this information was already a part of the form and it has been changed to comply with the Department of Treasury requirement.

VA is revising the VA Form 21-4142 to be compliant with Health and Human Services and Social Security Administration forms. This change will not add to the respondent burden.

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

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

19. 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.