Request for Employment Information in Connection with Claim for Disability Benefits

Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)

OMB: 2900-0065

IC ID: 28204

Information Collection (IC) Details

View Information Collection (IC)

Request for Employment Information in Connection with Claim for Disability Benefits 2900-0065 VBA-COMP-YM
 
No Modified
 
Voluntary
 
38 CFR 3.342 38 CFR 3.340 38 CFR 3.341

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form VA Form 21-4192 REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS VA Form 21-4192 (11-30-16).pdf www.va.gov/vaforms Yes No Fillable Printable

General Government Legislative Functions

 

60,000 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 60,000 0 0 0 0 60,000
Annual IC Time Burden (Hours) 15,000 0 0 0 0 15,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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