OMB2900-0405(21-8941)(8-27-14)

Supporting Statement for VA Form 21-8941

REPS Annual Eligibility Report

(Under the Provisions of Section 156, Public Law 97-377)

(2900-0405)

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. VA administers the Restored Entitlement Program for Survivors (REPS). This program pays VA benefits to certain surviving spouses and children of veterans who died in service prior to August 13, 1981 or who died as a result of a service-connected disability incurred or aggravated prior to August 13, 1981. The program is funded by the Department of Defense (DoD). Decisions as to entitlement are made by VA using Social Security Administration (SSA) entitlement criteria. Information is requested by this form under the authority of 38 U.S.C. 5101. Regulatory authority is found in 38 C.F.R. Sec. 3.812. The expiration date is being added to the form.

2. VA Form 21-8941 is used by the REPS Processing Unit at the St. Louis VA Regional Office to verify a REPS beneficiary’s entitlement factors including annual earnings, marital status, and status of children. The form is completed annually by beneficiaries who have earned income that is at or near the limit of earned income. Benefits are reduced when beneficiaries earn more than the annual limit.

3. VA Form 21-8941 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 information is necessary in order to determine whether a beneficiary continues to meet the eligibility criteria for REPS benefits. Without this information, VA would be unable to verify continued entitlement to REPS benefits in a timely fashion, and overpayments would result.

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 June 12, 2014, Volume79, No. 113 page 33805. 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 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).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

1. Number of Respondents is estimated at 1,200 per year.

2. Frequency of Response is annually for most beneficiaries.

3. Annual burden is 300 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 $7,200.00 (300 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 $26,360

(GS- 12/5 @ $40.66 x 1,200 x 15/60 minutes = $12,198)

(GS- 9/5 @ $28.04 x 1,200 x 20/60 minutes = $11,216)

(GS- 3/5 @ $14.73 x 1,200 x 10/60 minutes = $2,946)

2. Printing and production cost $100

3. Total cost to government $26,460

15. There is no change in the reporting burden hours. 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.