Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure (21-0964)

Documents and Forms

Document Name Document Type
Form 21-0964 Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure (21-0964) Form
21-0964 Statement in Support for Disability and Related Compensa VA Form 21-0964-New (2-18-14).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure (21-0964)	Agency IC Tracking Number:	2900-NEW VBA-COMP-YM

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.6

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-0964	Statement in Support for Disability and Related Compensation Benefits Due to Exposure	VA Form 21-0964-New (2-18-14).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	6,667	6,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.