Information Collection

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

IC 211174 under ICR 201404-2900-006 · OMB 2900-0827.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.