Income-Net Worth and Employment Statement (VA Form 21P-527) and Application for Pension (VA Form 21P-527EZ)

Forms and Documents

Document Name	Status
Form VA Form 21P-527 Income-Net Worth and Employment Statement Form	Modified
2900-0002SuppStmt (7-30-14).docx Supporting Statement A	2014-07-31

IC Document Collections

IC ID	Document Title	Status
28067	Income-Net Worth and Employment Statement Form	Modified

ICR Details

OMB Control No: 2900-0002	ICR Reference No: 201407-2900-020
Status: Historical Active	Previous ICR Reference No: 201406-2900-040
Agency/Subagency: VA	Agency Tracking No: 2900-0002 VBA-P&F-NK
Title: Income-Net Worth and Employment Statement (VA Form 21P-527) and Application for Pension (VA Form 21P-527EZ)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/30/2014
	Date Received in OIRA: 07/31/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	12/31/2015
Responses	118,197	0	104,440
Time Burden (Hours)	59,230	0	104,440
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21P-527 is necessary to obtain current employment, dependency, and family income and net worth information so VA can determine entitlement to disability pension. VA disability pension benefits are not payable without this information. VA Form 21P-527EZ, Application for Pension, is the prescribed form for disability pension claims, respectively, claimed under the FDC Program. This form is required as part of the FDC Program Transformation Initiative.

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Authorizing Statute(s): US Code: 38 USC 1503 Name of Law: Disability Pension Program
   US Code: 38 USC 1502 Name of Law: Disability Pension Program
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO81	Final or interim final rulemaking	78 FR 211	10/31/2013

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Income-Net Worth and Employment Statement	VA Form 21P-527, VA Form 21P-527EZ	Income, Net Worth and Employment Statement ,   Application for Pension

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ICR Summary 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	118,197	104,440	0	13,757	0	0
Annual Time Burden (Hours)	59,230	104,440	0	-45,210	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There is a decrease in the respondent burden due to 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.

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Annual Cost to Federal Government: $4,486,740

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

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Common Form ICR:  No

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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: 07/31/2014

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