Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)

ICR 201501-2900-006

OMB: 2900-0826

Federal Form Document

IC Document Collections
ICR Details
2900-0826 201501-2900-006
Historical Active 201407-2900-019
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)
Revision of a currently approved collection   No
Approved without change 07/09/2015
Retrieve Notice of Action (NOA) 05/22/2015
  Inventory as of this Action Requested Previously Approved
07/31/2018 36 Months From Approved 07/31/2015
724,561 0 724,561
181,140 0 181,140
0 0 0

VA Form 21-0966 will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or pension, or survivors pension and/or DIC, to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.

US Code: 38 USC 5102 Name of Law: Application forms furnished upon request; notice to claimants of incomplete applications

Not associated with rulemaking

  80 FR 27 02/10/2015
80 FR 89 05/08/2015

  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 724,561 724,561 0 0 0 0
Annual Time Burden (Hours) 181,140 181,140 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0

Crystal Rennie 202 632-7492 [email protected]


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:
    (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;
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.

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