Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)

ICR 201602-2900-037 · OMB 2900-0736 · Historical Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0736 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form VA Form 21-0845 Authorization to Disclose Personal Information to a Third Party	Form	Modified	Available
2016-06272, 60-Day FRN (2900-0736, VAF 21-0845).pdf	Supplementary Document	Uploaded 2016-05-04	Repair queued
2900-0736, (VAF21-0845), SS, (5-4-16).docx	Supporting Statement A	Uploaded 2016-05-04	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
188786	Authorization to Disclose Personal Information to a Third Party	Form	Modified

ICR Details

OMB Control No: 2900-0736	ICR Reference No: 201602-2900-037
Status: Historical Active	Previous ICR Reference No: 201301-2900-003
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)
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: 09/12/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/23/2016
Terms of Clearance: VBA is to update BLS information and re-upload as a non-substantive change.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved	09/30/2016
Responses	20,000	0	20,000
Time Burden (Hours)	1,667	0	1,667
Cost Burden (Dollars)	0	0	0

Abstract: VA Form 21-0845 is used to release information in the following circumstances: where the individual identifies the particular information and consents to its use; for the purpose for which it was collected or a consistent purpose (i.e., a purpose which the individual might have reasonably expected).

Authorizing Statute(s): US Code: 5 USC 552a Name of Law: Privacy Act Law
US Code: 38 USC 5701 Name of Law: Confidential nature of claims

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:
	81 FR 6272	03/21/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 14676	06/22/2016
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
Authorization to Disclose Personal Information to a Third Party	VA Form 21-0845	Authorization to Disclose Personal Information to a Third Party

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	20,000	20,000
Annual Time Burden (Hours)	1,667	1,667
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: $256,788

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: Cynthia Harvey - Pryor 202 461-5870 [email protected]

Common Form ICR: No