Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0826 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC Form
VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension, 21-0966(4-30-15).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

IC Title:	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	Agency IC Tracking Number:	2900-0826

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0966	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	21-0966(4-30-15).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 724,561	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Previously Approved
Annual Number of Responses for this IC	724,561	724,561
Annual IC Time Burden (Hours)	181,140	181,140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.