Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)

ICR 202010-2900-011 · OMB 2900-0856 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0856 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form VA Form 29-0975 AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION	Form	Modified	Repair queued
2021-02650.pdf	Supplementary Document	Uploaded 2021-02-09	Repair queued
SupportingState(2900-0856).docx	Supporting Statement A	Uploaded 2021-02-09	Repair queued
2020-24308.pdf	Supplementary Document	Uploaded 2020-12-22	Missing upstream

IC Document Collections

IC ID	Collection	Type	Status	Form
220731	AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION	Form	Modified

ICR Details

OMB Control No: 2900-0856	ICR Reference No: 202010-2900-011
Status: Received in OIRA	Previous ICR Reference No: 201507-2900-007
Agency/Subagency: VA	Agency Tracking No: VBA-INS-NK
Title: Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 02/09/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,200	0
Time Burden (Hours)	100	0
Cost Burden (Dollars)	0	0

Abstract: This form will be used by the Department of Veterans Affairs Insurance Center (VAIC) to enable a third party to act on behalf of the insured Veteran/beneficiary. Many of our customers are of advanced age or suffer from limiting disabilities and need assistance from a third party to conduct their affairs. The information collected provides an optional service and is not required to receive insurance benefits.

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 24308	11/03/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 2650	02/09/2021
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION	VA Form 29-0975	Authorization to Disclose Personal Information to a Third Party (Insurance)

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,200	0	1,200
Annual Time Burden (Hours)	100	100	0
Annual Cost Burden (Dollars)	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: There is a small increase due to an increase in use of this form.

Annual Cost to Federal Government: $6,630

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? No

Agency Contact: Maribel Aponte 202 266-4688 [email protected]

Common Form ICR: No