Marital Status Questionnaire (21-0537)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 21-0537 Marital Status Questionnaire	Form	Modified	Available
Suppl Stmt - DOMA, 21-0537 (non-sub).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-06-19	Available
Supporting Statement for VAF 21-0537 082913.doc	Supporting Statement A	Uploaded 2013-08-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28678	Marital Status Questionnaire	Form	Modified

ICR Details

OMB Control No: 2900-0495	ICR Reference No: 201406-2900-022
Status: Historical Active	Previous ICR Reference No: 201303-2900-013
Agency/Subagency: VA	Agency Tracking No: 2900-0495 VBA-COMP-YM
Title: Marital Status Questionnaire (21-0537)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/19/2014
	Date Received in OIRA: 06/19/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	09/30/2016	09/30/2016
Responses	2,286	0	2,286
Time Burden (Hours)	191	0	191
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Form 21-0537 is necessary to determine whether a surviving spouse is still entitled to DIC benefits.

---

Authorizing Statute(s): US Code: 38 USC 6102 Name of Law: Fraudulent acceptance of payments
   US Code: 38 USC 1506 Name of Law: Resource reports and overpayment adjustments
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 80	04/25/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 155	08/12/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Marital Status Questionnaire	21-0537	Marital Status Questionnaire

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,286	2,286	0	0	0	0
Annual Time Burden (Hours)	191	191	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $3,059

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/19/2014

---