Information Collection

Statement of Marital Relationship (VA Form 21-4170)

IC 28314 under ICR 202404-2900-005 · OMB 2900-0114.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-4170 Statement of Marital Relationship (VA Form 21-4170)	Form
Form 21-4170 Statement of Marital Relationship Statement of Marital Relationship (VA Form 21-4170)	Form
21-4170 Statement of Marital Relationship VA Form 21-4170 (OMB Exp. 7-31-24).pdf	Form
21-4170 Statement of Marital Relationship VA Form 21-4170 (OMB Exp. 7-31-24).pdf	Form

IC Title:

Agency IC Tracking Number:

2900-0114

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	21-4170			www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title: 58VA21/22/28 Compensation, Pension, Education, and Veteran Readiness & Employment Records

FR Citation: 87 FR 8740

Number of Respondents: 1,984

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,984	-221	2,205
Annual IC Time Burden (Hours)	827	-92	919
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.

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