Information Collection

Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)

IC 28927 under ICR 202305-2900-006 · OMB 2900-0652.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)	Form
VA Form 21-0779 Request for Nursing Home Information in Connection with 21-0779(8-4-23).pdf www.va.gov/vaforms	Form
VA Form 21-0779 Request for Nursing Home Information in Connection with 21-0779(8-4-23).pdf www.va.gov/vaforms	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.351 38 CFR 3.551

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 21-0779	Request for Nursing Home Information in Connection with Claim for Aid and Attendance	21-0779(8-4-23).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title: Compensation, Pension, Education, and Veterans Readiness and Employment Records-VA (58VA21/22/28)

FR Citation: 88 FR 16751

Number of Respondents: 17,367

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17,367	-43,758	61,125
Annual IC Time Burden (Hours)	2,895	-7,293	10,188
Annual IC Cost Burden (Dollars)	0	-201,519	201,519

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.