2900-0095 Revisions Description

2900-0095 Revisions Description.docx

Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)

2900-0095 Revisions Description

OMB: 2900-0095

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Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)
OMB 2900-0095

Substantive Changes to the Collection

  • Added a field for the first, middle, and last name of the claimant (if the claimant is not the Veteran)

  • Removed the field “VA Office and Address”

  • Modified the field “Names and Owners of Business and Degree of Ownership of Each” by creating a two-column table. The first column will be used for the name of the owner, and the second column used to describe the degree of ownership.

  • Modified the field “Farm Operating Expenses” to simplify the form. The number of fillable column fields has been reduced from five to two, which allows for a simpler calculation of total expenses.

  • Removed fields for “Acreage Rented to Others,” “Acreage Rented From Others,” and “Total Acreage Operated by You.” If this information applies, it will be provided separately (see field 10).

  • Added fields 7B “Is your primary residence located on the acreage you own?” 7C “If you answered "Yes" to 8B, how many of the acres you own are considered part of your primary residence?” and 7D “If you answered "Yes" to 8B, what is the specific value of the acreage related to your primary residence?”

  • Removed the table which requested the proportion of farm work done by the claimant, the proportion of work completed by hired help, and the proportion of work completed by others.

  • Removed the field which asked the claimant to describe any work performed for others in the past year and associated wage and salary information.

  • Removed the filed which requested the claimant report income from any source other than farming.



Non-Substantive Changes to the Collection

  • Updated Privacy Act Notice to include appropriate language regarding the collection of Social Security Numbers

  • Updated the respondent burden statement to better describe affected benefit programs and provide a more accurate toll-free assistance number

  • Removed the statement of penalty for fraudulent submission.

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSUPPORTING STATEMENT FOR VA FORM 10-2065, FUNERAL ARRANGEMENTS; VA FORM 10-10, APPLICATION FOR MEDICAL BENEFITS; VA FORM 10-10I,
AuthorPreferred Customer
File Modified0000-00-00
File Created2021-01-23

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