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Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)

ICR 201911-2900-009 · OMB 2900-0652 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form Modified Available
2020-01941, 30-Day FRN (2900-0652).pdf Supplementary Document Uploaded 2020-02-07 Available
60-Day FRN - 2900-0652 (2019).pdf Supplementary Document Uploaded 2020-01-07 Available
2900-0652, Supp Stmt (VAF 21-0779).docx Supporting Statement A Uploaded 2020-02-07 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
28927 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form Modified
ICR Details
2900-0652 201911-2900-009
Active 201602-2900-005
VA VBA-COMP-YA
Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)
Extension without change of a currently approved collection   No
Regular
Approved with change 08/07/2020
Retrieve Notice of Action (NOA) 02/10/2020
  Inventory as of this Action Requested Previously Approved
08/31/2023 36 Months From Approved 08/31/2020
61,125 0 61,125
10,188 0 10,188
201,519 0 201,519
VA Form 21-0779 is used to gather the necessary information to determine eligibility for pension and aid and attendance based on being in a nursing home. This form also requests information on Medicaid status and nursing home care charges, so VA can determine the proper rate of payment.
US Code: 38 USC 1502 Name of Law: Determination with respect to disability
   US Code: 38 USC 1115(1)(E) Name of Law: Aid and attendance
   US Code: 38 USC 1311(c) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1315(h) Name of Law: Dependency and Indemnity compensation to parents
   US Code: 38 USC 5503 Name of Law: Hospitalized veterans and estates of incompetent institutionalized veterans
   US Code: 38 USC 501(a)(2) Name of Law: Rules and regulations
  
None
Not associated with rulemaking
  84 FR 66707 12/05/2019
85 FR 6021 02/03/2020
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 61,125 61,125 0 0 0 0
Annual Time Burden (Hours) 10,188 10,188 0 0 0 0
Annual Cost Burden (Dollars) 201,519 201,519 0 0 0 0
No
No
$10,243,010
No
    Yes
    Yes
No
No
No
No
Danny Green 202 421-1354 [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.
02/10/2020