OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)

ICR 201507-2900-007 · OMB 2900-0856 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 29-0975 AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION Form New Available
30-Day FRN - 2900-NEW (VA Form 29-0975) 2017.pdf Supplementary Document Uploaded 2017-06-06 Available
60-Day FRN - 2900-NEW (VA Form 29-0975) 2017.pdf Supplementary Document Uploaded 2017-01-25 Available
Supporting Statement for 2900-NEW (VA Form 29-0975) 8-30-17.doc Supporting Statement A Uploaded 2017-08-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
220731 AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION Form New
ICR Details
2900-0856 201507-2900-007
Historical Active
VA VBA-INS-YA
Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 11/14/2017
Retrieve Notice of Action (NOA) 09/14/2017
  Inventory as of this Action Requested Previously Approved
11/30/2020 36 Months From Approved
1,200 0 0
0 0 0
0 0 0
This form will be used by the Department of Veterans Affairs Insurance Center (VAIC) to enable a third party to act on behalf of the insured Veteran/beneficiary. Many of our customers are of advanced age or suffer from limiting disabilities and need assistance from a third party to conduct their affairs. The information collected provides an optional service and is not required to receive insurance benefits.
None
None
Not associated with rulemaking
  82 FR 6729 01/19/2017
82 FR 20688 05/03/2017
No
1
IC Title Form No. Form Name
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION VA Form 29-0975 AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY (INSURANCE)
  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 1,200 0 0 1,200 0 0
Annual Time Burden (Hours) 0 0 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$3,681
No
    Yes
    Yes
No
No
No
Uncollected
Nancy Kessinger 202 632-8924 [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.
09/14/2017