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Federal forms, ICRs, and supporting documents

Information Collection Request

Beneficiary Travel Mileage Reimbursement Application Form

ICR 201304-2900-019 · OMB 2900-0798 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 10-3542 VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES Form and Instruction New Repair queued
10-3542 10-23-13.pdf Supplementary Document Uploaded 2013-10-23 Repair queued
Memo on revisions to 10-3542_10-9-13 (v3) (10.21.13).docx Supplementary Document Uploaded 2013-10-21 Available
10-3542 BT Claim Form __Minor-Rev Sept 24 (10.21.13).pdf Supplementary Document Uploaded 2013-10-21 Repair queued
Justification_Beneficiary Travel Application (v2).docx Supporting Statement A Uploaded 2013-08-20 Available
IC Document Collections
IC IDCollectionTypeStatusForm
206581 VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES Form and Instruction New
ICR Details
2900-0798 201304-2900-019
Historical Active
VA
Beneficiary Travel Mileage Reimbursement Application Form
Existing collection in use without an OMB Control Number   No
Regular
Approved without change 12/13/2013
Retrieve Notice of Action (NOA) 08/29/2013
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved
11,600,000 0 0
580,000 0 0
0 0 0
The information collection is for beneficiaries to apply for the BT mileage reimbursement benefit. VHA determines the identity of the claimant, the dates and length of the trip being claimed based on addresses of starting and ending points, , and whether expenses other than mileage are being claimed. The claimant is required to sign the form. The form is used only when the claimant chooses not to apply verbally and is provided for their convenience. Once the information is obtained it is entered into a software program that calculates the mileage and resulting reimbursement.
US Code: 38 USC Section 111 Name of Law: Payments or allowances for beneficiary travel
  
None
Not associated with rulemaking
  78 FR 115 06/14/2013
78 FR 168 08/29/2013
No
1
IC Title Form No. Form Name
VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES VA Form 10-3542 VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
  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 11,600,000 0 0 0 0 11,600,000
Annual Time Burden (Hours) 580,000 0 0 0 0 580,000
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$1,500,000
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/29/2013