Information Collection

Statement of Marital Relationship (VA Form 21-4170)

IC 28314 under ICR 202404-2900-005 · OMB 2900-0114.

Documents and Forms

Document Name Document Type
Form 21-4170 Statement of Marital Relationship (VA Form 21-4170) Form
21-4170 Statement of Marital Relationship VA Form 21-4170 (OMB Exp. 7-31-24).pdf www.va.gov/vaforms Form
21-4170 Statement of Marital Relationship VA Form 21-4170 (OMB Exp. 7-31-24).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	21-4170	Statement of Marital Relationship	VA Form 21-4170 (OMB Exp. 7-31-24).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 Veteran Readiness & Employment Records	FR Citation: 87 FR 8740

Number of Respondents: 1,984	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,984	-221	2,205
Annual IC Time Burden (Hours)	827	-92	919
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.