Request for Nursing Home Information in Connection with Claim for Aid and Attendance

Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0652 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form
VA Form 21-0779 Request for Nursing Home Information in Connection with 21-0779(3-7-16).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

IC Title:	Request for Nursing Home Information in Connection with Claim for Aid and Attendance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.351 38 CFR 3.551

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0779	Request for Nursing Home Information in Connection with Claim for Aid and Attendance	21-0779(3-7-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)	FR Citation: 74 FR 29275

Number of Respondents: 61,125	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	61,125	11,125	50,000
Annual IC Time Burden (Hours)	10,188	1,855	8,333
Annual IC Cost Burden (Dollars)	201,519	201,519	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.