Claim for One Sum Payment (Government Life Ins), Claim for Monthly Payments (National Service Life Ins), and Claim for One Sum Payment (Government Life Ins) VA Forms 29-4125, 4125A, 4125e-Electronic

Forms and Documents

Document Name	Status
Form 29-4125 Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance Form	Modified
30-Day FRN - 2900-0060 (2022).pdf Supplementary Document	2022-01-18
60-Day FRN - 2900-0060 (2021).pdf Supplementary Document	2022-01-04
VA Form 29-4125e DocuSign Snapshot.docx Supplementary Document	2021-12-08
Supporting Statement.docx Supporting Statement A	2021-10-19

IC Document Collections

IC ID	Document Title	Status
28196	Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance Form	Modified

ICR Details

OMB Control No: 2900-0060	ICR Reference No: 202110-2900-003
Status: Received in OIRA	Previous ICR Reference No: 201901-2900-003
Agency/Subagency: VA	Agency Tracking No: VBA-INS-YA
Title: Claim for One Sum Payment (Government Life Ins), Claim for Monthly Payments (National Service Life Ins), and Claim for One Sum Payment (Government Life Ins) VA Forms 29-4125, 4125A, 4125e-Electronic
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/18/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2022
Responses	120,100	120,100
Time Burden (Hours)	12,010	12,010
Cost Burden (Dollars)	0	0

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Abstract: The VA Forms 29-4125, 29-4125A and 29-4125e are used by beneficiaries to request the proceeds from Government Life Insurance policies. The information is required by law, 38 U.S.C. 1917 and 1952.

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Authorizing Statute(s): US Code: 38 USC 1952 Name of Law: Optional Settlement
   US Code: 38 USC 1917 Name of Law: Insurance Maturing on or after August 1, 1946
  

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 59006	10/25/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 2670	01/18/2022
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Claim for One Sum Payment (Government Life Insurance), Claim for Monthly Payments (National Service Life Insurance), and Claim for Monthly Payments, U.S. Government Insurance	29-4125, 29-4125a, 29-4125e	Claim for One Sum Payment (Government Life Insurance) ,   Claim for Monthly Payments National Life Insurance ,   Claim for One Sum Payment (Government Life Insurance) - Electronic Form

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ICR Summary 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	120,100	120,100	0	0	0	0
Annual Time Burden (Hours)	12,010	12,010	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $780,704

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: 01/18/2022

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