Information Collection

Supporting Statement Regarding Marriage (VA Form 21P-4171)

IC 28317 under ICR 202012-2900-003 · OMB 2900-0115.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0115 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21P-4171 Supporting Statement Regarding Marriage (VA Form 21P-4171)	Form
21P-4171 Supporting Statement Regarding Marriage VA Form 21P-4171 (OMB Exp. 3-31-21).pdf www.va.gov/vaforms	Form
21P-4171 Supporting Statement Regarding Marriage VA Form 21P-4171 (508 CONFORMANT 12-22-20).pdf www.va.gov/vaforms	Form

IC Title:

Supporting Statement Regarding Marriage (VA Form 21P-4171)

Agency IC Tracking Number:

2900-0115

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.1(j) 38 CFR 3.50

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	21P-4171	Supporting Statement Regarding Marriage	VA Form 21P-4171 (508 CONFORMANT 12-22-20).pdf	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 and Employment Records - VA

FR Citation: 77 FR 42593

Number of Respondents: 2,400

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	19,088	19,088

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.