Income-Net Worth and Employment Statement

OMB Control No: 2900-0002	ICR Reference No: 201309-2900-005
Status: Historical Inactive	Previous ICR Reference No: 201203-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0002 VBA-P&F-NK
Title: Income-Net Worth and Employment Statement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 12/13/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/19/2013
Terms of Clearance: VA should resubmit this ICR once the final rule is developed.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	12/31/2015
Responses	104,440	0	104,440
Time Burden (Hours)	104,440	0	104,440
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-527 is necessary to obtain current employment, dependency, and family income and net worth information so VA can determine entitlement to disability pension. VA disability pension benefits are not payable without this information.

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Authorizing Statute(s): US Code: 38 USC 1503 Name of Law: Disability Pension Program    US Code: 38 USC 1502 Name of Law: Disability Pension Program

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO81	Proposed rulemaking	78 FR 211	10/31/2013

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title Form No. Form Name Income-Net Worth and Employment Statement VA Form 21-527 Income-Net Worth and Income Statement

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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: Yes

Burden Reduction Due to: Changing Regulations

Short Statement: There is a change in the annual expected number of respondents due to the Notice of Proposed Rulemaking (NPRM) RIN 2900-AO81, "Standard Claims and Appeals Forms" which proposes to require all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA expects that more respondents will be filing pension claims in the fully developed claim program which requires the use of VA Form 21-527EZ.

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Annual Cost to Federal Government: $892,980

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

Agency Contact: Crystal Rennie 202 632-7492 [email protected]

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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: 09/19/2013

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