OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Intent to File a Claim for Compensation and/or Pension, Survivors Pension, or Other Benefits (VA Form 21-0966)

ICR 201407-2900-019 · OMB 2900-0826 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21-0966 INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, SURVIVORS PENSION, OR OTHER BENEFITS Form New Available
SuppStmt, VAF 21-0966, 7-30-14.docx Supporting Statement A Uploaded 2014-07-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
212535 INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, SURVIVORS PENSION, OR OTHER BENEFITS Form New
ICR Details
2900-0826 201407-2900-019
Historical Active
VA 2900-NEW - COMP-NK
Intent to File a Claim for Compensation and/or Pension, Survivors Pension, or Other Benefits (VA Form 21-0966)
New collection (Request for a new OMB Control Number)   No
Emergency 04/17/2014
Approved with change 11/19/2014
Retrieve Notice of Action (NOA) 07/30/2014
VA shall seek public comment and submit an extension of this collection within six months if it wishes to continue to collect this information.
  Inventory as of this Action Requested Previously Approved
05/31/2015 6 Months From Approved
724,561 0 0
181,140 0 0
0 0 0
VA Form 21-0966 will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or disability benefits to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.
Resubmited due to form revision.
US Code: 38 USC 5102 Name of Law: Application forms furnished upon request; notice to claimants of incomplete applications
  
None
2900-AO81 Final or interim final rulemaking 79 FR 57660 09/25/2014
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 724,561 0 0 724,561 0 0
Annual Time Burden (Hours) 181,140 0 0 181,140 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The respondent burden increases because VA Form 21-0966 is a new form and will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or disability benefits to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.
$5,135,607
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.
07/30/2014