Veteran's Application for Compensation and or Pension (21-526), Veteran's Supplemental Claim Application (21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)
Veteran's Application for Compensation and or Pension (21-526), Veteran's Supplemental Claim Application (21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)
Terms of the previous clearance remain in effect. VA has requested withdrawal of this
information collection request.
Inventory as of this Action
Requested
Previously Approved
03/31/2016
36 Months From Approved
03/31/2016
595,000
0
595,000
441,982
0
441,982
0
0
0
VA Forms 21-526 and 21-526b are used to gather the necessary information to determine a veteran's eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible.
VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA.
This information collection is associated with the AO81 Rule.
Burden increased because we added a new form.
VA has newly created the VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). The new VA Form 21-4142a is created to gather PHP information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.
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.
Form VA Form 21-4142 Veteran's Application for Compensation and/ or Pension(21-526), Supplemental Application for Compensation(21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)
21-4142 Supplemental Stmt (2-25-14).docx
Veteran's Application for Compensation and/ or Pension(21-526), Supplemental Application for Compensation(21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)