Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (VA Form 21-4502)

Forms and Documents

Document Name	Status
Form VA Form 21-4502 Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) Form	Modified
Supplemental Stmt 2900-0067 (21-4502).docx Supplementary Document	2015-01-13
2900-0067, SuppStmt, 1-7-15.docx Supporting Statement A	2015-01-13

IC Document Collections

IC ID	Document Title	Status
28212	Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) Form	Modified

ICR Details

OMB Control No: 2900-0067	ICR Reference No: 201408-2900-015
Status: Historical Active	Previous ICR Reference No: 201107-2900-005
Agency/Subagency: VA	Agency Tracking No: 2900-0067 VBA-COMP-NK
Title: Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (VA Form 21-4502)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/16/2015
	Date Received in OIRA: 10/15/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved	01/31/2015
Responses	1,552	0	1,552
Time Burden (Hours)	388	0	388
Cost Burden (Dollars)	9,312	0	0

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Abstract: VA Form 21-4502 is used to gather information that is necessary to determine the entitlement of veterans and servicepersons to automobile and adaptive equipment benefits. Without this information, VA would be unable to properly authorize benefits.

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Authorizing Statute(s): US Code: 38 USC 3902 Name of Law: Assistance for providing automobile and adaptive equipment
   US Code: 38 USC 3904 Name of Law: Research and development
   US Code: 38 USC 3901 Name of Law: Definitions
   US Code: 38 USC 3903 Name of Law: Limitations on assistance; special training courses
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 33805	06/12/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 58867	09/30/2014
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
Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904)	VA Form 21-4502	Application for Automobile or Other Conveyance and Adaptive Equipment

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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	1,552	1,552	0	0	0	0
Annual Time Burden (Hours)	388	388	0	0	0	0
Annual Cost Burden (Dollars)	9,312	0	0	9,312	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:

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Annual Cost to Federal Government: $32,729

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: 10/15/2014

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