OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Nursing Home Information in Connection with Claim for Aid and Attendance

ICR 201304-2900-024 · OMB 2900-0652 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form Modified Available
Supporting Statement for VAF 21-0779 04-19-13 .doc Supporting Statement A Uploaded 2013-08-08 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28927 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form Modified
ICR Details
2900-0652 201304-2900-024
Historical Active 201006-2900-011
VA 2900-0652 VBA-COMP-NK
Request for Nursing Home Information in Connection with Claim for Aid and Attendance
Extension without change of a currently approved collection   No
Regular
Approved without change 11/07/2013
Retrieve Notice of Action (NOA) 09/09/2013
  Inventory as of this Action Requested Previously Approved
11/30/2016 36 Months From Approved 12/31/2013
50,000 0 50,000
8,333 0 8,333
0 0 0
VA Form 21-0779 is used to gather the necessary information to determine eligibility for pension and aid and attendance based on being in a nursing home. This form also requests information on Medicaid status and nursing home care charges, so VA can determine the proper rate of payment.
US Code: 38 USC 1502 Name of Law: Determination with respect to disability
   US Code: 38 USC 1115(1)(E) Name of Law: Aid and attendance
   US Code: 38 USC 1311(c) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1315(h) Name of Law: Dependency and Indemnity compensation to parents
   US Code: 38 USC 5503 Name of Law: Hospitalized veterans and estates of incompetent institutionalized veterans
   US Code: 38 USC 501(a)(2) Name of Law: Rules and regulations
  
None
Not associated with rulemaking
  78 FR 97 05/20/2013
78 FR 166 08/27/2013
No
  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 50,000 50,000 0 0 0 0
Annual Time Burden (Hours) 8,333 8,333 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$1,323,250
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.
09/09/2013