2900-0736, (vaf21-0845), Ss, (5-4-16)

2900-0736, (VAF21-0845), SS, (5-4-16).docx

Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)

OMB: 2900-0736

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Authorization to Disclose Personal Beneficiary/Claimant Information to a Third Party

VA Form 21-0845

OMB 2900-0736


  1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for Veterans, service personnel, and their dependents and/or beneficiaries. Information is requested by this form under the authority of 5 U.S.C. 552a and 38 U.S.C. 5701 as implemented by 38 CFR 1.526(a) and 38 CFR 1.576(b).

VA Form 21-0845 has been revised to include optical character recognition formatting along with the addition of two new data collections; date of birth and Veteran’s service number. These new additions do not increase the burden.

  1. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

VA Form 21-0845 is used to release information in its custody or control in the following circumstances: where the individual identifies the particular information and consents to its use; for the purpose for which it was collected or a consistent purpose (i.e., a purpose which the individual might have reasonably expected). By law, VA must have a claimants or beneficiary’s written permission (an "authorization") to use or give out claim or benefit information for any purpose that is not contained in VA’s System of Records, 58VA21/22/28 Compensation, Pension, Education and Vocational Rehabilitation and Employment Records. The claimant or beneficiary may revoke the authorization at any time, except if VA has already acted based on the claimant’s permission.

  1. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

VA Form 21-0845 is available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database.

  1. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.

  1. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of information does not involve small businesses or entities.

  1. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

The VA compensation and pension programs require that statements submitted by or on behalf of a claimant contain certification by the respondent that the information provided is true and correct. This form is designed to facilitate claims processing by providing a uniform format for the certification statement.

  1. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

  1. A. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The Department notice was published in the Federal Register on March 21, 2016, Volume 81, No. 54, page 15151. No comments were received in response to this notice.

  1. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

This submission does not involve any recordkeeping costs.

  1. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts to respondents have been made under this collection of information.

  1. Describe any assurance of privacy to the extent permitted by law provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22/28, “Compensation, Pension, Education, and Rehabilitation Records—VA” as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).

  1. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

  1. Estimate of the hour burden of the collection of information:

  1. Number of Annual Respondents is estimated at 20,000.

  2. The time estimate to complete the form is 5 minutes.

  3. The annual hour burden is estimated at 1,667 hours.

  1. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

Frequency of Response is one time for this form.

  1. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14 of the OMB 83-I.

The respondent population for VA Form 21-0845 is composed of claimants or beneficiaries who authorize the VA to disclose information to an individual or organization. VBA cannot, make further assumptions about the population of respondents because of the variability of factors such as educational background and wage potential of respondents. Therefore, VBA used general wage data to estimate the respondents’ costs associated with completing the information collection.

The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the median weekly earnings of full-time wage and salary workers are $809.00. Assuming a forty (40) hour work week, the median hourly wage is $20.23.

Legally, respondents may not pay a person or business for assistance in completing the information collection and a person or business may not accept payment for assisting a respondent in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $33,723.41 (1,667 burden hours x $20.23 per hour).

  1. Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

This submission does not involve any recordkeeping costs.

  1. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

Estimated Costs to the Federal Government:

    1. Processing/Analyzing Costs with Overhead $253,966

  • GS-11/3 @ $32.12 x 20,000 x 5/60 minutes = $53,533

Overhead at 100% of Salary= $53,533

  • GS-9/3 @ $26.55 x 20,000 x 5/60 minutes = $44,250

Overhead at 100% of Salary= $44,250

  • GS-5/3 @ $17.52 x 20,000 x 5/60 minutes = $29,200

Overhead at 100% of Salary= $29,200

Overhead costs are 100% of salary and are same as the wage listed above and the amounts are included in the total.

    1. Printing and production cost ($90/thousand) $2,822

    1. Total cost to government $256,788

  1. Explain the reason for any burden hour changes since the last submission.

VA Form 21-0845 has been revised to include optical character recognition formatting along with the addition of two new data collections; date of birth and Veteran’s service number. These new additions do not increase the burden.

  1. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

The information collection is not for publication or tabulation use.

  1. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

We are not seeking approval to omit the expiration date for OMB approval.

  1. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

No statistical methods are used in this data collection.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSupporting Statement for VA Form 21-4502
File Modified0000-00-00
File Created2021-01-24

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