Information Collection

Statement of Marital Relationship (VA Form 21-4170)

IC 28314 under ICR 202009-2900-015 · OMB 2900-0114.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0114 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-4170 Statement of Marital Relationship (VA Form 21-4170) Form
VA Form 21-4170 Statement of Marital Relationship 21-4170(10-5-20).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Marital Relationship (VA Form 21-4170)	Agency IC Tracking Number:	2900-0114

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-4170	Statement of Marital Relationship	21-4170(10-5-20).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation & Employment Records	FR Citation: 84 FR 4138

Number of Respondents: 2,205	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,205	-4,295	6,500
Annual IC Time Burden (Hours)	919	-1,789	2,708
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.