Election to Waive, Retain, or Re-Elect Due Process Rights if in Receipt of Concurrent Active Duty Service Pay and Disability Compensation Pay (VA Form 21-10213)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VAF 21-10213 Election to Waive, Retain, or Re-Elect Due Process Rights if in Receipt of Concurrent Active Duty Service Pay and Disability Compensation Pay (VA Form 21-10213)	Form	New	Repair queued
2021-24420.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
2021-18689, 60-Day FRN (VAF21-10213).pdf	Supplementary Document	Uploaded 2021-11-03	Repair queued
2900-NEW, Supporting Statement (VAF 21-10213).docx	Supporting Statement A	Uploaded 2021-11-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249004	Election to Waive, Retain, or Re-Elect Due Process Rights if in Receipt of Concurrent Active Duty Service Pay and Disability Compensation Pay (VA Form 21-10213)	Form	New

ICR Details

OMB Control No:	ICR Reference No: 202108-2900-019
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Election to Waive, Retain, or Re-Elect Due Process Rights if in Receipt of Concurrent Active Duty Service Pay and Disability Compensation Pay (VA Form 21-10213)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/09/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	100,000	0
Time Burden (Hours)	8,333	0
Cost Burden (Dollars)	0	0

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Abstract: VA Form 21-10213, will be used to determine whether an election to waive due process rights is acknowledged, re-elected, or cancelled when a veteran is in receipt of concurrent active duty service pay and disability compensation pay. Without this collection of information, determination of election would not be possible. This is a new collection.

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Authorizing Statute(s): US Code: 38 USC 501 Name of Law: Rules and Regulations
   US Code: 38 USC 5101(a) Name of Law: Claims and Forms
   US Code: 38 USC 5304(c) Name of Law: Prohibition of Duplication of Benefits
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 18689	08/31/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 24420	11/09/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Election to Waive, Retain, or Re-Elect Due Process Rights if in Receipt of Concurrent Active Duty Service Pay and Disability Compensation Pay (VA Form 21-10213)	VAF 21-10213	Election to Waive, Retain, or Re-Elect Due Process Rights if in Receipt of Concurrent Active Duty Service Pay and Disability Compensation Pay

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ICR Summary of Burden

table that charts list of burden

	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	100,000	0	0	100,000	0	0
Annual Time Burden (Hours)	8,333	0	0	8,333	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $1,526,272

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 11/09/2021

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