Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA 21-4193 Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution	Form	Modified	Available
2900-0116 30Day FRN.pdf	Supplementary Document	Uploaded 2017-06-30	Available
2017-07397, 60-Day FRN (21-4193).pdf	Supplementary Document	Uploaded 2017-04-13	Available
2900-0116, Supporting Stmt for 21-4193.docx	Supporting Statement A	Uploaded 2017-06-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28320	Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution	Form	Modified

ICR Details

OMB Control No: 2900-0116	ICR Reference No: 201612-2900-015
Status: Historical Active	Previous ICR Reference No: 201307-2900-015
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DJ
Title: Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/18/2017
	Date Received in OIRA: 06/30/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved	09/30/2017
Responses	1,664	0	1,664
Time Burden (Hours)	416	0	416
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Form 21-4193 is used to gather information from penal institutions about incarcerated VA beneficiaries. When beneficiaries are incarcerated in penal institutions in excess of 60 days after conviction, VA benefits are reduced or terminated. Without this collection of information, VA would be unable to accurately adjust the rates of incarcerated beneficiaries and overpayments would result.

---

Authorizing Statute(s): US Code: 38 USC 1505 Name of Law: Payment of pension during confinement in penal institutions
   US Code: 38 USC 5313 Name of Law: Limitation on payment of compensation and dependency and indemnity compensation to persons incarcera
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 17742	04/12/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 30007	06/30/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution	VA 21-4193	Notice to Department of Veterans Affairs of Veteran or Benefiiciary Incarcerated in Penal Institution

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,664	1,664	0	0	0	0
Annual Time Burden (Hours)	416	416	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $71,505

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/30/2017

---