Authorization To Disclose Personal Information To A Third Party (insurance)

Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0856 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 29-0975 AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION Form
VA Form 29-0975 Authorization to Disclose Personal Information to a Thir 29-0975(10-22-2020).pdf www.va.gov/vaforms Form
29-0975e Authorization to Disclose Information to a Third Party I VA Form 29-0975e (DocuSign) 6-24-22.pdf Form
29-0975 AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIR VA Form 29-0975 Non-sub 8-8-22.pdf www.va.gov/vaforms Form
29-0975e Authorization to Disclose Information to a Third Party I VA Form 29-0975e (DocuSign) 6-24-22.pdf Form

Information Collection (IC) Details

IC Title:	AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY (INSURANCE)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	29-0975	AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY (INSURANCE)	VA Form 29-0975 Non-sub 8-8-22.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	29-0975e	Authorization to Disclose Information to a Third Party Insurance	VA Form 29-0975e (DocuSign) 6-24-22.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records - VA	FR Citation: 86 FR 2650

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.