Notice of Disagreement (VA Form 21-0958)

OMB Control No: 2900-0791	ICR Reference No: 201401-2900-003
Status: Historical Active	Previous ICR Reference No: 201206-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0791 VBA-COMP-NK
Title: Notice of Disagreement (VA Form 21-0958)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/30/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/30/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved	03/31/2016
Responses	144,000	0	144,000
Time Burden (Hours)	72,000	0	72,000
Cost Burden (Dollars)	0	0	0

---

Abstract: This form is used to initiate disagreement with VA regarding a decision on a claim in order to file an appeal. VA Form 21-0958, this form is associated with the AO81 rule.

---

Authorizing Statute(s): US Code: 38 USC 1521(d) and (e) Name of Law: Veterans of a period of war    US Code: 38 USC 1114 Name of Law: Rates of wartime disability compensation    US Code: 38 USC 1151(1)(E) Name of Law: Benefits for persons disabled by treatment or vocational rehabilitation    US Code: 38 USC 1311(d) Name of Law: Dependency and indemnity compensation to a surviving spouse    US Code: 38 USC 1541(d) and (e) Name of Law: Surviving spouses of veterans of a period of war    US Code: 38 USC 7105(a) Name of Law: Filing notice of disagreement and appeal

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

IC Title Form No. Form Name Notice of Disagreement (21-0958) VA Form 21-0958 Notice of Disagreement

---

ICR Summary 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	144,000	144,000	0	0	0	0
Annual Time Burden (Hours)	72,000	72,000	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:

---

Annual Cost to Federal Government: $7,229,520

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]

---

Common Form ICR:  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:
		(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: 07/30/2014

---