Marital Status Questionnaire (21P-0537)

Forms and Documents

Document Name	Status
Form 21P-0537 Marital Status Questionnaire Form	Modified
2900-0495 30-Day FRN.pdf Supplementary Document	2019-04-16
2900-0495 60-Day FRN.pdf Supplementary Document	2019-04-05
2900-0495 Supporting Statement.docx Supporting Statement A	2019-09-10

IC Document Collections

IC ID	Document Title	Status
28678	Marital Status Questionnaire Form	Modified

ICR Details

OMB Control No: 2900-0495	ICR Reference No: 201901-2900-007
Status: Active	Previous ICR Reference No: 201602-2900-003
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-YA
Title: Marital Status Questionnaire (21P-0537)
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: 09/16/2019
	Date Received in OIRA: 05/30/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	09/30/2019
Responses	17,808	0	17,808
Time Burden (Hours)	1,484	0	1,484
Cost Burden (Dollars)	0	0	30,021

---

Abstract: VA Form 21P-0537 is used to verify a surviving spouse’s current marital status to verify his or her continuing entitlement to DIC benefits. The form letter is automatically generated and mailed to DIC beneficiaries. Agency action depends on the information provided by the beneficiary. If the information provided supports the beneficiary’s continued entitlement to benefits, no action is taken. If the information provided by the beneficiary does not support continued entitlement to benefits, VA will take action to terminate benefit payments, based on the facts found.

---

Authorizing Statute(s): US Code: 38 USC 103 Name of Law: Special Provisions Relating to Marriages
   US Code: 38 USC 101(3) Name of Law: Definition of Surviving Spouse
  

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:
	84 FR 2949	02/08/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 15678	04/16/2019
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
Marital Status Questionnaire	21P-0537	Marital Status Questionnaire

---

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	17,808	17,808	0	0	0	0
Annual Time Burden (Hours)	1,484	1,484	0	0	0	0
Annual Cost Burden (Dollars)	0	30,021	0	-30,021	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: $612,536

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: 05/30/2019

---