Reports of: General Information, First Notice of Death, Nursing Home or Assisted Living, Defense Finance & Accounting, Non-Receipt of Payment, Incarceration, Month of Death (VA Forms 27-0820 series)

Forms and Documents

Document	Type	Status	Availability
Form VA Form 27-0820b Reports of: General Info., First Notice of Death, Nursing Home or Assisted Living, Defense Finance & Accounting, Non-Receipt of Payment, Incarceration, Month of Death	Form	Modified	Available
2018-09056.pdf	Supplementary Document	Uploaded 2018-05-17	Available
2900-0734 Supporting Statement v.2 clean.docx	Supporting Statement A	Uploaded 2018-07-16	Repair queued
2018-02363.pdf	Supplementary Document	Uploaded 2018-02-15	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
187592	Reports of: General Info., First Notice of Death, Nursing Home or Assisted Living, Defense Finance & Accounting, Non-Receipt of Payment, Incarceration, Month of Death	Form	Modified

ICR Details

OMB Control No: 2900-0734	ICR Reference No: 201712-2900-006
Status: Active	Previous ICR Reference No: 201411-2900-005
Agency/Subagency: VA	Agency Tracking No: VBA-BAS-NK
Title: Reports of: General Information, First Notice of Death, Nursing Home or Assisted Living, Defense Finance & Accounting, Non-Receipt of Payment, Incarceration, Month of Death (VA Forms 27-0820 series)
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 with change	Conclusion Date: 07/23/2018
	Date Received in OIRA: 06/01/2018
Terms of Clearance: We appreciate VA's agreement to report back on the actual number of form submissions when this collection is renewed.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	36 Months From Approved	09/30/2018
Responses	2,550,000	0	2,550,000
Time Burden (Hours)	212,500	0	212,500
Cost Burden (Dollars)	0	0	0

---

Abstract: These forms will be used by VA Regional Office and Pension Maintenance Center employees to meet our requirement to document verbal evidence obtained telephonically from our beneficiary or claimant that will be used as part of the evidence for a claim for benefits.

---

Authorizing Statute(s): None

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:
	83 FR 2363	02/07/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 9056	04/30/2018
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Reports of: General Info., First Notice of Death, Nursing Home or Assisted Living, Defense Finance & Accounting, Non-Receipt of Payment, Incarceration, Month of Death	VA Form 27-0820b, VA Form 27-0820e, VA Form 27-0820d, VA Form 27-0820, VA Form 27-0820c, VA Form 27-0820f, VA Form 27-0820a	Report of Nursing Home or Assisted Living Information ,   Report of Defense Finance & Accounting Service (DFAS) ,   Report of Non-Receipt of Payment ,   Report of Incarceration ,   Report of Month of Death ,   Report of First Notice of Death ,   Report of General Information

---

ICR Summary 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	2,550,000	2,550,000	0	0	0	0
Annual Time Burden (Hours)	212,500	212,500	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: $62,917,259

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: 06/01/2018

---