OMB2900-0075(21-4138)(9-16-14)

Supporting Statement for VA Form 21-4138

Statement in Support of Claim

(2900-0075)

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. Information is requested by this form under the authority of 38 U.S.C. 501 and 38 C.F.R. 3.150. The expiration date is being added to the form.

2. VA Form 21-4138 is used by claimants to provide self-certified statements in support of various types of claims processed by the agency.

3. VA Form 21-4138 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. The VA compensation and pension programs require that statements submitted by or on behalf of a claimant contain certification by the respondent that the information provided is true and correct. This form is designed to facilitate claims processing by providing a uniform format for the certification statement.

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 July 17, 2014, Volume 79, No. 137, page 41744. No comments were received in response to this notice.

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 Respondents is estimated at 752,000 per year.

2. Frequency of Response is on occasion for most beneficiaries.

3. Annual burden is 188,000 hours.

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

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 $4,512,000 (188,000 burden hours x $24 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

1. Processing/Analyzing costs $27,639,509

(GS-12/5 @ $40.66 x 752,000 x 15/60 minutes = $ 7,644,080)

(GS-9/5 @ $28.04 x 752,000 x 47/60 minutes = $16,517,429)

(GS-5/5 @ $18.50 x 752,000 x 15/60 minutes = $ 3,478,000)

2. Printing and production cost $22,560

3. Total cost to government $27,662,069

15. There is no change in the reporting burden. The expiration date is being added to the form.

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

This collection of information does not employ statistical methods.