Information Collection

Status of Dependents Questionnaire

IC 28684 under ICR 201609-2900-012 · OMB 2900-0500.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0500 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-0538 Status of Dependents Questionnaire	Form
21-0538 STATUS OF DEPENDENTS QUESTIONNAIRE VA Form 21-0538 (10-11-16) 508 Conformant.pdf www.va.gov/vaforms	Form

IC Title:

Status of Dependents Questionnaire

Agency IC Tracking Number:

2900-0500

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.652

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-0538	STATUS OF DEPENDENTS QUESTIONNAIRE	VA Form 21-0538 (10-11-16) 508 Conformant.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: 84,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	84,500	0	0	84,500
Annual IC Time Burden (Hours)	14,083	0	0	14,083
Annual IC Cost Burden (Dollars)	211,245	-362,355	362,355	211,245

Documents for IC

table that charts IC Documents
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.