Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)

Forms and Documents

Document Name	Status
Form 21P-4165 Pension Claim Questionnaire for Farm Income Form	Modified
2900-0095 30-Day FRN.pdf Supplementary Document	2019-06-03
2900-0095 60-Day FRN 20190325.pdf Supplementary Document	2019-03-25
2900-0095 Supporting Statement.docx Supporting Statement A	2019-07-02

IC Document Collections

IC ID	Document Title	Status
28263	Pension Claim Questionnaire for Farm Income Form	Modified

ICR Details

OMB Control No: 2900-0095	ICR Reference No: 201902-2900-003
Status: Active	Previous ICR Reference No: 201604-2900-009
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-YA
Title: Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)
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: 12/12/2019
	Date Received in OIRA: 07/02/2019
Terms of Clearance: Approval is granted on the condition that VA submit a non-substantive change request within 45 days of issuance of the NOA that modifies "Your obligation to respond is required to obtain or retain benefits" to "Your response is required to obtain or retain benefits" in the Privacy Act statement and removes the requirement that the witnesses in Section V be personally known to the claimant.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	12/31/2019
Responses	2,075	0	2,075
Time Burden (Hours)	1,038	0	1,038
Cost Burden (Dollars)	0	0	20,988

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Abstract: VA Form 21P-4165 (Formerly VA Form 21-4165) is used to gather information which is necessary to determine a claimant's countable annual income and available assets related to farm operations. Eligibility to income-based benefits cannot be determined without complete income information.

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Authorizing Statute(s): US Code: 38 USC 1521 Name of Law: Veterans of a period of war
   US Code: 38 USC 1541 Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 1542 Name of Law: Children of veterans of a period of war
   US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income
   US Code: 38 USC 1522 Name of Law: Net worth limitation
   US Code: 38 USC 1543 Name of Law: Net worth limitation
  

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:
	84 FR 11166	03/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 25338	05/31/2019
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Pension Claim Questionnaire for Farm Income	21P-4165	Pension Claim Questionnaire for Farm Income

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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	2,075	2,075	0	0	0	0
Annual Time Burden (Hours)	1,038	1,038	0	0	0	0
Annual Cost Burden (Dollars)	0	20,988	0	-20,988	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: $57,301

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: 07/02/2019

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