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

ICR 201801-2900-004

OMB: 2900-0826

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
2900-0826 201801-2900-004
Active 201501-2900-006
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)
Extension without change of a currently approved collection   No
Approved without change 08/22/2018
Retrieve Notice of Action (NOA) 06/21/2018
  Inventory as of this Action Requested Previously Approved
08/31/2021 36 Months From Approved 08/31/2018
724,561 0 724,561
181,140 0 181,140
0 0 0

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.

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

Not associated with rulemaking

  83 FR 6100 02/12/2018
83 FR 8370 04/23/2018

  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

Cynthia Harvey - Pryor 202 461-5870 [email protected]


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:
    (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;
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.

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