Application for Disability Compensation and Related Compensation Benefits (VA Form 21-526EZ)

Forms and Documents

Document Name	Status
Form VA Form 21-526EZ Application for Disability Compensation and Related Compensation Benefits Form	Modified
2019-07106.pdf Supplementary Document	2019-04-19
2900-0747 Comment-Response 2019.docx Supplementary Document	2019-03-22
2900-0747, Supporting Statement (VAF 21-526EZ).docx Supporting Statement A	2019-04-16
2018-25256.pdf Supplementary Document	2018-11-20

IC Document Collections

IC ID	Document Title	Status
191044	Application for Disability Compensation and Related Compensation Benefits Form	Modified

ICR Details

OMB Control No: 2900-0747	ICR Reference No: 201811-2900-001
Status: Active	Previous ICR Reference No: 201711-2900-006
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Application for Disability Compensation and Related Compensation Benefits (VA Form 21-526EZ)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/16/2019
	Date Received in OIRA: 05/15/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	03/31/2021
Responses	1,360,000	0	34,813
Time Burden (Hours)	498,667	0	14,505
Cost Burden (Dollars)	0	0	0

---

Abstract: Public Law 110-389, Section 221(a)directs the Department of Veterans Affairs (VA) to expeditiously process fully developed compensation and pension claims within 90 days after receipt of the claim. VA Form 21-526EZ is used to collect the information needed to process a fully developed claim for disability compensation and/or related compensation benefits. Though the law requires the claimant submit a certification in writing that states no additional information or evidence is available or needs to be submitted in order for the claim to be adjudicated via the fully developed claim program, the form has evolved into a standard claim form to be used for any benefit associated with disability compensation; to include new or initial claims, reopened claims, and claims for increase.

---

Authorizing Statute(s): PL: Pub.L. 110 - 389 221 Name of Law: Veterans¿ Benefits Improvement Act of 2008
   US Code: 38 USC 5101 Name of Law: Claims and Forms
  

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 25256	11/20/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 7106	04/10/2019
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
Application for Disability Compensation and Related Compensation Benefits	VA Form 21-526EZ	Application for Disability Compensation and Related Compensation Benefits

---

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	1,360,000	34,813	0	1,325,187	0	0
Annual Time Burden (Hours)	498,667	14,505	0	484,162	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: VA Form 21-526EZ is being resubmitted to correct the previous estimate of burden. The publication of RIN 2900-AO81, Standard Claims and Appeals final rule on 9/24/2014, required submission of all claims on a standardized form, greatly increasing the total number of respondents. Unfortunately, the previous justification did not include updates to the increase in respondents and burden estimate. This resubmission corrects that error. Within the new burden estimate, VA has separated out the paper and electronic burdens for tracking/informational purposes as we move to continue improving our electronic claims process. VA increased the burden, due to: • New or initial claims received, • Reopened claims received, • Increased claims received, and • General program changes, such as regulatory changes and the discontinuance of other claim forms (if any). This new estimate of respondents has increased the burden estimate.

---

Annual Cost to Federal Government: $59,253,538

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: 05/15/2019

---