Information Collection

Application for Benefits for Certain Children with Disabilities Born of Vietnam and Certain Korea Service Veterans

IC 28777 under ICR 201407-2900-016 · OMB 2900-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0572 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-0304 Application for Benefits for Certain Children with Disabilities Born of Vietnam and Certain Korea Service Veterans	Form
21-0304 Application for Benefits for Certain Children with Disab 21-0304.pdf www.vba.va.gov/pubs/forms/21-0304.pdf	Form

IC Title:

Application for Benefits for Certain Children with Disabilities Born of Vietnam and Certain Korea Service Veterans

Agency IC Tracking Number:

2900-0572

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	21-0304	Application for Benefits for Certain Children with Disabilities Born of Vietnam and Certain Korea Service Veteran	21-0304.pdf	www.vba.va.gov/pubs/forms/21-0304.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 430

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	430	0	430
Annual IC Time Burden (Hours)	72	0	72
Annual IC Cost Burden (Dollars)	1,728	1,728	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.