Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	Form	Modified	Available
2018-08370.pdf	Supplementary Document	Uploaded 2018-04-23	Available
2018-02712, 60-Day FRN (2900-0826).pdf	Supplementary Document	Uploaded 2018-02-28	Available
2900-0826, Supporting Stmt (VAF 21-0966).docx	Supporting Statement A	Uploaded 2018-06-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212535	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	Form	Modified

ICR Details

OMB Control No: 2900-0826	ICR Reference No: 201801-2900-004
Status: Active	Previous ICR Reference No: 201501-2900-006
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)
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: 08/22/2018
	Date Received in OIRA: 06/21/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	08/31/2018
Responses	724,561	0	724,561
Time Burden (Hours)	181,140	0	181,140
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-0966 will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or pension, or survivors pension and/or DIC, to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.

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Authorizing Statute(s): US Code: 38 USC 5102 Name of Law: Application forms furnished upon request; notice to claimants of incomplete applications
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 6100	02/12/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 8370	04/23/2018
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	VA Form 21-0966	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

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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	724,561	724,561	0	0	0	0
Annual Time Burden (Hours)	181,140	181,140	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:

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Annual Cost to Federal Government: $14,865,912

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

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Common Form ICR:  No

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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: 06/21/2018

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