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Federal forms, ICRs, and supporting documents

Information Collection Request

Supplemental Income Questionnaire (For Philippine Claims Only) (VA Form 21P-0784)

ICR 201708-2900-005 · OMB 2900-0668 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21P-0784 Supplemental Income Questionnaire (For Philippine Claims Only) (21P-0784) Form Modified Repair queued
2900-0668 30-Day FRN.pdf Supplementary Document Uploaded 2017-12-19 Available
2900-0668 60-Day FRN.pdf Supplementary Document Uploaded 2017-12-07 Available
2900-0668 Supporting Statement.docx Supporting Statement A Uploaded 2017-12-12 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28946 Supplemental Income Questionnaire (For Philippine Claims Only) (21P-0784) Form Modified
ICR Details
2900-0668 201708-2900-005
Active 201312-2900-012
VA VBA-P&F-NK
Supplemental Income Questionnaire (For Philippine Claims Only) (VA Form 21P-0784)
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 03/05/2018
Retrieve Notice of Action (NOA) 12/27/2017
  Inventory as of this Action Requested Previously Approved
03/31/2021 36 Months From Approved
120 0 0
30 0 0
716 0 0
VA Form 21P-0784 is used to gather income information that is necessary to determine a claimant's entitlement to pension benefits. It is used only by Philippine claimants who reside in the Philippines. Without information about a claimant's family income and net worth, VA would not be able to properly determine entitlement to pension and the rate payable.
US Code: 38 USC 1541 Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 1542 Name of Law: Children of veterans of a period of war
   US Code: 38 USC 107 Name of Law: Certain service deemed not to be active service
   US Code: 38 USC 1506 Name of Law: Resource reports and overpayment adjustments
   US Code: 38 USC 1521 Name of Law: Veterans of a period of war
  
None
Not associated with rulemaking
  82 FR 47080 10/10/2017
82 FR 60277 12/19/2017
No
1
IC Title Form No. Form Name
Supplemental Income Questionnaire (For Philippine Claims Only) (21P-0784) VA Form 21P-0784 Supplemental Income Questionnaire (Phillipine Claims Only)
  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 120 0 0 0 0 120
Annual Time Burden (Hours) 30 0 0 0 0 30
Annual Cost Burden (Dollars) 716 0 0 716 0 0
No
No
$2,980
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.
12/27/2017