Information Collection

Income and Asset Statement in Support of Claim for

IC 214403 under ICR 201412-2900-019 · OMB 2900-0829.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0829 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21P-0969 Income and Asset Statement in Support of Claim for	Form
VA Form 21P-0969 Income and Asset Statement in Support of Claim for Pensi 21P-0969(12-23-14).pdf www.va.gov/vaforms	Form

IC Title:

Income and Asset Statement in Support of Claim for

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.5 38 CFR 3.3 38 CFR 3.275

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	VA Form 21P-0969	Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC)	21P-0969(12-23-14).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60,000

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
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	600,000	600,000

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.