Fiduciary Statement in Support of Appointment (21P-0792)

OMB Control No: 2900-0670	ICR Reference No: 201704-2900-001
Status: Historical Active	Previous ICR Reference No: 201405-2900-017
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-YA
Title: Fiduciary Statement in Support of Appointment (21P-0792)
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: 12/08/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/22/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved	03/31/2018
Responses	43,000	0	7,500
Time Burden (Hours)	10,750	0	1,875
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21P-0792 will be completed by individuals who are seeking to be appointed as fiduciaries of VA beneficiaries. The information will be used by VA field examiners to determine whether an individual is an appropriate fiduciary for a VA beneficiary and make an inquiry into his or her credit and criminal background.

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Authorizing Statute(s): US Code: 38 USC 5507 Name of Law: Inquiry, Investigations, and Qualifications of Fiduciaries

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 27331	06/14/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 40063	08/23/2017
Did the Agency receive public comments on this ICR? No

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

IC Title Form No. Form Name Fiduciary Statement in Support of Appointment (21P-0792) 21P-792 Fiduciary Statement in Support of Appointment

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ICR Summary of Burden

	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	43,000	7,500	0	0	35,500	0
Annual Time Burden (Hours)	10,750	1,875	0	0	8,875	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This submission reports an increase of burden hours since the last submission. The increase in burden is based on an increase of beneficiary's requiring fiduciary services. Changes to the form include removing the Veteran/beneficiary social security number and changing the expiration date to be in standard with OMB. The expiration date placeholder has been added to the form.

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Annual Cost to Federal Government: $102,906

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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]

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Common Form ICR:  No

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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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 09/22/2017

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