Statement of Disappearance (VA Form 21P-1775)

OMB Control No: 2900-0036	ICR Reference No: 201902-2900-002
Status: Active	Previous ICR Reference No: 201604-2900-005
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-YA
Title: Statement of Disappearance (VA Form 21P-1775)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/19/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/02/2019
Terms of Clearance: In its next revision or extension request for this collection, VA shall modify "Your obligation to respond is required to obtain or retain benefits" to "You are required to respond to obtain or retain benefits" in the Privacy Act statement and shall consult the VA Privacy Office on whether the routine uses listed in the Privacy Act statement satisfy the requirements of 5 USC 552a(e)(3)(C).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	12/31/2019
Responses	10	0	10
Time Burden (Hours)	28	0	28
Cost Burden (Dollars)	0	0	566

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Abstract: Since no state law providing presumption of death is applicable to VA benefits, VA Form 21P-1775 is needed to gather sufficient information from a claimant so a formal decision can be made regarding the unexplained absence of an individual for over 7 years.

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Authorizing Statute(s): US Code: 38 USC 108 Name of Law: presumption of death

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:
	84 FR 11167	03/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 25338	05/31/2019
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 Statement of Disappearance 21P-1775, 21P-1775 VA Form 21P-1775 ,   Statement of Disappearance

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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	10	10	0	0	0	0
Annual Time Burden (Hours)	28	28	0	0	0	0
Annual Cost Burden (Dollars)	0	566	0	-566	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:

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Annual Cost to Federal Government: $503

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: 07/02/2019

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