OMB.report

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 202305-2900-006 · OMB 2900-0652 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779) Form Modified Repair queued
2023-16751, 30-Day FRN (2900-0652).pdf Supplementary Document Uploaded 2023-08-07 Repair queued
2023-11409, 60-Day FRN (2900-0652).pdf Supplementary Document Uploaded 2023-08-07 Repair queued
2900-0652, Supporting Statement (VAF 21-0779), 8-7-23.docx Supporting Statement A Uploaded 2023-08-07 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
28927 Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779) Form Modified
ICR Details
2900-0652 202305-2900-006
Received in OIRA 201911-2900-009
VA VBA-COMP-NK
Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)
Revision of a currently approved collection   No
Regular 08/07/2023
  Requested Previously Approved
36 Months From Approved 08/31/2023
17,367 61,125
2,895 10,188
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. Without this collection of information, determination of payment would not be possible.
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
   US Code: 38 USC 1502 Name of Law: Determination with respect to disability
  
None
Not associated with rulemaking
  88 FR 34566 05/30/2023
88 FR 52259 08/07/2023
No
  Total Request 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 17,367 61,125 0 -43,758 0 0
Annual Time Burden (Hours) 2,895 10,188 0 -7,293 0 0
Annual Cost Burden (Dollars) 0 201,519 0 -201,519 0 0
No
Yes
Miscellaneous Actions
The burden has decreased since the previous approval due to the estimated number of receivables averaged over the past year.
$415,322
No
    Yes
    Yes
No
No
No
No
Maribel Aponte 202 266-4688 [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.
08/07/2023