Information Collection

Statement of Marital Relationship (VA Form 21-4170)

IC 28314 under ICR 202009-2900-015 · OMB 2900-0114.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0114 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-4170 Statement of Marital Relationship (VA Form 21-4170)	Form
Form VA Form 21-4170 Statement of Marital Relationship Statement of Marital Relationship (VA Form 21-4170)	Form
VA Form 21-4170 Statement of Marital Relationship 21-4170(10-5-20).pdf	Form
VA Form 21-4170 Statement of Marital Relationship 21-4170(10-5-20).pdf	Form

IC Title:

Statement of Marital Relationship (VA Form 21-4170)

Agency IC Tracking Number:

2900-0114

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-4170			www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title: 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation & Employment Records

FR Citation: 84 FR 4138

Number of Respondents: 2,205

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,205	-4,295	6,500
Annual IC Time Burden (Hours)	919	-1,789	2,708
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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