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Statement of Marital Relationship (VA Form 21-4170)
Statement of Marital Relationship (VA Form 21-4170)
OMB: 2900-0114
IC ID: 28314
OMB.report
VA
OMB 2900-0114
ICR 202009-2900-015
IC 28314
( )
Documents and Forms
Document Name
Document Type
Form VA Form 21-4170
Statement of Marital Relationship (VA Form 21-4170)
Form
VA Form 21-4170 Statement of Marital Relationship
21-4170(10-5-20).pdf
www.va.gov/vaforms
Form
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
VA Form 21-4170
Statement of Marital Relationship
21-4170(10-5-20).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
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 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
2,205
0
-4,295
0
6,500
0
Annual IC Time Burden (Hours)
919
0
-1,789
0
2,708
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.
