Information Collection

Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)

IC 212535 under ICR 202111-2900-007 · OMB 2900-0826.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0826 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)	Form
VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension o 21-0966(1-11-23).pdf www.va.gov/vaforms	Form
VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension o 21-0966(1-11-23).pdf www.va.gov/vaforms	Form

IC Title:

Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)

Agency IC Tracking Number:

2900-0826

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.155

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	VA Form 21-0966	Intent to File a Claim for Compensation and/or Pension or Survivors Pension and/or DIC	21-0966(1-11-23).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title: 58VA 21/22/28, Compensation, Pension, Education, Veterans Readiness and Employment Records - VA

FR Citation: 87 FR 8740

Number of Respondents: 409,394

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	409,394	-315,167	724,561
Annual IC Time Burden (Hours)	102,348	-78,792	181,140
Annual IC Cost Burden (Dollars)	0	0	0

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.