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

ICR 201501-2900-006 · OMB 2900-0826 · Historical Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0826 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	Form	Modified	Repair queued
201501-2900-006_2900-0826 SuppStmt (21-0966) (7-7-15).docx	Supporting Statement A	Uploaded 2015-07-07	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
212535	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	Form	Modified

ICR Details

OMB Control No: 2900-0826	ICR Reference No: 201501-2900-006
Status: Historical Active	Previous ICR Reference No: 201407-2900-019
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/09/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/22/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2015
Responses	724,561	0	724,561
Time Burden (Hours)	181,140	0	181,140
Cost Burden (Dollars)	0	0	0

Abstract: 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 pension, or survivors pension and/or DIC, to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.

Authorizing Statute(s): US Code: 38 USC 5102 Name of Law: Application forms furnished upon request; notice to claimants of incomplete applications

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 27	02/10/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 89	05/08/2015
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC	VA Form 21-0966	Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	724,561	724,561
Annual Time Burden (Hours)	181,140	181,140
Annual Cost Burden (Dollars)	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: $5,135,608

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