Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 21P-4165 Pension Claim Questionnaire for Farm Income	Form and Instruction	Modified	Available
Form 21P-4165 Pension Claim Questionnaire for Farm Income	Form and Instruction	Modified	Repair queued
Public comment 2900-0095.docx	Public Comments	Uploaded 2025-09-04	Repair queued
30-DAY (published) 2900-0095.pdf	Supplementary Document	Uploaded 2025-08-26	Repair queued
30-DAY (published) 2900-0095.pdf	Supplementary Document	Uploaded 2025-08-26	Missing upstream
60-Day FRN (published) 2900-0095.pdf	Supplementary Document	Uploaded 2025-08-22	Repair queued
60-Day FRN (published) 2900-0095.pdf	Supplementary Document	Uploaded 2025-08-22	Missing upstream
2900-0095 (21P-4165) - Supporting Statement 8-26-25.docx	Supporting Statement A	Uploaded 2025-08-26	Repair queued
2900-0095 (21P-4165) - Supporting Statement 8-26-25.docx	Supporting Statement A	Uploaded 2025-08-26	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28263	Pension Claim Questionnaire for Farm Income	Form and Instruction	Modified	Pension Claim Questionnaire for Farm Income
28263	Pension Claim Questionnaire for Farm Income	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0095	ICR Reference No: 202502-2900-011
Status: Active	Previous ICR Reference No: 202204-2900-013
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-YA
Title: Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/01/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/26/2025
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2028	36 Months From Approved	11/30/2025
Responses	218	0	218
Time Burden (Hours)	109	0	109
Cost Burden (Dollars)	0	0	0

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Abstract: The VA Form 21P-4165 (Formerly VA Form 21-4165) is used to gather information which is necessary to determine a claimant's countable annual income and available assets related to farm operations. Eligibility to income-based benefits cannot be determined without complete income information.

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Authorizing Statute(s): US Code: 38 USC 1522 Name of Law: Net worth limitation
   US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income
  

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:
	90 FR 26682	06/23/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 41633	08/26/2025
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Pension Claim Questionnaire for Farm Income	21P-4165	Pension Claim Questionnaire for Farm Income

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	218	218	0	0	0	0
Annual Time Burden (Hours)	109	109	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: $10,964

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: 08/26/2025

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