Supplemental Income Questionnaire (For Philippine Claims Only) (VA Form 21P-0784)

ICR 202102-2900-007

OMB: 2900-0668

Federal Form Document

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IC Document Collections
ICR Details
2900-0668 202102-2900-007
Received in OIRA 201708-2900-005
Supplemental Income Questionnaire (For Philippine Claims Only) (VA Form 21P-0784)
Reinstatement without change of a previously approved collection   No
Regular 06/08/2021
  Requested Previously Approved
36 Months From Approved
120 0
30 0
716 0

VBA administers Pension Benefits, which is a needs-based benefit program for wartime Veterans, who are aged 65 or older or have a permanent and total non-service-connected disability and limited income and net worth. Eligibility is determined based on the income of and asset amounts for the Veteran and their spouse. Claimants residing in the Philippines complete VAF21P-0784, Supplemental Income Questionnaire (for Philippine Claims Only), to report their countable family income and net worth. VBA uses the information to determine the claimant’s entitlement to pension benefits.

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 107 Name of Law: Certain service deemed not to be active service
   US Code: 38 USC 1506 Name of Law: Resource reports and overpayment adjustments
   US Code: 38 USC 1521 Name of Law: Veterans of a period of war

Not associated with rulemaking

  86 FR 11056 02/23/2021
86 FR 25067 05/10/2021

IC Title Form No. Form Name
Supplemental Income Questionnaire (For Philippine Claims Only) (VA Form 21P-0784) VA Form 21P-0784 Supplemental Income Questionnaire (Philippine Claims Only)

  Total Request 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 120 0 0 0 0 120
Annual Time Burden (Hours) 30 0 0 0 0 30
Annual Cost Burden (Dollars) 716 0 0 0 0 716

Maribel Aponte 202 266-4688 [email protected]


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.

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