Supporting Statement for:
(2900-0067)
VA Form 21-4502 |
Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) |
A. Justification
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.
The Final Rule RIN 2900-AO81, Standard Claims and Appeals Forms, which requires all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA is codifying its regulations to standardize the use of all VA forms, to include VA Forms 21-4502.
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.
VA Form 21-4502 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.
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.
The collection of information does not involve small businesses or entities.
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.
There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
The Department notice was published in the Federal Register on June 12, 2014, Vol. 79, No. 113, pages 33805 and 33806. No comments were received in response to this notice.
The Department notice was published in proposed rule, RIN 2900-AO81, Standard Claims and Appeals Forms, in the Federal Register on October 31, 2013, Vol. 78, No. 211, pages 65490-65509. No comments were received.
No payments or gifts to respondents have been made under this collection of information.
The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22/28, “Compensation, Pension, Education, and Rehabilitation Records—VA,” as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
There are no questions of a sensitive nature.
Estimate of Information Collection Burden.
Number of Respondents is estimated at 1,552 per year.
Frequency of Response is one time.
Annual burden is 388 hours.
The estimated completion time is 15 minutes.
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 $9,312 (388 burden hours x $24 per hour).
This submission does not involve any recordkeeping costs.
Estimated Costs to the Federal Government:
Processing/Analyzing costs $32,370
(GS-12/5 @ $40.66 x 1,552 x 15/60 minutes = $15,776)
(GS- 9/5 @ $28.04 x 1,552 x 15/60 minutes = $10,879)
(GS- 3/5 @ $14.73 x 1,552 x 15/60 minutes = $ 5,715)
Forms are available on the VA inter/intranet forms websites.
Printing and production cost ($90/thousand) $359
Total cost to government $32,729
The reporting burden has not changed even with the Final Rulemaking RIN 2900-AO81, Standard Claims and Appeals Forms, which requires 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 expiration date placeholder has been added to the form.
We are not seeking approval to omit the expiration date for OMB approval.
The information collection is not for publication or tabulation use.
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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for VA Form 21-4502 |
| Author | VBA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |