OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193)

ICR 201612-2900-015 · OMB 2900-0116 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA 21-4193 Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution Form Modified Available
2900-0116 30Day FRN.pdf Supplementary Document Uploaded 2017-06-30 Available
2017-07397, 60-Day FRN (21-4193).pdf Supplementary Document Uploaded 2017-04-13 Available
2900-0116, Supporting Stmt for 21-4193.docx Supporting Statement A Uploaded 2017-06-26 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28320 Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution Form Modified
ICR Details
2900-0116 201612-2900-015
Historical Active 201307-2900-015
VA VBA-COMP-DJ
Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193)
Extension without change of a currently approved collection   No
Regular
Approved without change 09/18/2017
Retrieve Notice of Action (NOA) 06/30/2017
  Inventory as of this Action Requested Previously Approved
09/30/2020 36 Months From Approved 09/30/2017
1,664 0 1,664
416 0 416
0 0 0
VA Form 21-4193 is used to gather information from penal institutions about incarcerated VA beneficiaries. When beneficiaries are incarcerated in penal institutions in excess of 60 days after conviction, VA benefits are reduced or terminated. Without this collection of information, VA would be unable to accurately adjust the rates of incarcerated beneficiaries and overpayments would result.
US Code: 38 USC 1505 Name of Law: Payment of pension during confinement in penal institutions
   US Code: 38 USC 5313 Name of Law: Limitation on payment of compensation and dependency and indemnity compensation to persons incarcera
  
None
Not associated with rulemaking
  82 FR 17742 04/12/2017
82 FR 30007 06/30/2017
Yes
  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 1,664 1,664 0 0 0 0
Annual Time Burden (Hours) 416 416 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$71,505
No
    Yes
    Yes
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 [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.
06/30/2017