Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)

ICR 201903-2900-015

OMB: 2900-0736

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2019-09-12
Supplementary Document
2019-08-06
Supplementary Document
2019-05-14
IC Document Collections
ICR Details
2900-0736 201903-2900-015
Active 201602-2900-037
VA VBA-COMP-NK
Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)
Extension without change of a currently approved collection   No
Regular
Approved without change 04/24/2020
Retrieve Notice of Action (NOA) 09/12/2019
In its next revision or extension request of this collection, VA shall: 1. Allow the respondent to request information to be shared with an organization (rather than a specific representative of an organization), or provide a legal opinion from VA OGC that such a change would be inconsistent with regulation or statute and 2. That the mailing address of the respondent is an option field.
  Inventory as of this Action Requested Previously Approved
04/30/2022 36 Months From Approved 04/30/2020
20,000 0 20,000
1,667 0 1,667
0 0 0

VA Form 21-0845 is used to release information in the following circumstances: where the individual identifies the particular information and consents to its use; for the purpose for which it was collected or a consistent purpose (i.e., a purpose which the individual might have reasonably expected).

US Code: 38 USC 5701 Name of Law: Confidential nature of claims
   US Code: 5 USC 552a Name of Law: Privacy Act Law
  
None

Not associated with rulemaking

  84 FR 9248 05/07/2019
84 FR 16023 07/29/2019
No

1
IC Title Form No. Form Name
Authorization to Disclose Personal Information to a Third Party VA Form 21-0845 Authorization to Disclose Personal Information to a Third Party

  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 20,000 20,000 0 0 0 0
Annual Time Burden (Hours) 1,667 1,667 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$256,788
No
    Yes
    Yes
No
No
No
Uncollected
Danny Green 202 421-1354 [email protected]

  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:
 
 
 
 
 
 
 
    (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.
09/12/2019


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