View Information Collection Request (ICR) Package

OMB Control No: 2900-0829	ICR Reference No: 201809-2900-003
Status: Historical Active	Previous ICR Reference No: 201412-2900-019
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-NK
Title: Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC) (VA Form 21P-0969)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/23/2018
	Date Received in OIRA: 09/18/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved
Responses	60,000	0	0
Time Burden (Hours)	25,000	0	0
Cost Burden (Dollars)	0	0	0

Abstract: The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. Information is requested by this form under the authority of: • 38 U.S.C. § 1503 Determinations with respect to annual income • 38 U.S.C. § 1541 Surviving spouses of veterans of a period of war • 38 U.S.C. § 1543 Net worth limitation • 38 U.S.C. § 1315 Dependency and indemnity compensation to parents In RIN 2900-AO73, VA proposes to amend its pension regulations to maintain the integrity of its needs-based pension program. VA has authority under 38 U.S.C. 501(a) to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by VA. VA would amend its information collections in conjunction with RIN 2900-AO73. This rulemaking is largely in response to a Government Accountability Office (GAO) report, GAO-12-50, Veterans’ Pension Benefits: Improvements Needed to Ensure Only Qualified Veterans and Survivors Receive Benefits. VA Form 21P-0969 will be used by claimants for VA Pension or Parents' Dependency and Indemnity Compensation (DIC) to provide information pertaining to income and assets to establish entitlement to Pension or Parents' DIC. This form will be completed only by those claimants who had income other than Social Security benefits during the calendar year before claiming benefits or who disposed of assets or have significant assets which may affect their entitlement to needs-based benefits.

Authorizing Statute(s): US Code: 38 USC 1541 Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 1543 Name of Law: Net worth limitation
   US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income
   US Code: 38 USC 1315 Name of Law: Dependency and indemnity compensation to parents

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO73	Final or interim final rulemaking	83 FR 47246	09/18/2018

Federal Register Notices & Comments
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
Income and Asset Statement in Support of Claim for	VA Form 21P-0969

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	60,000	60,000
Annual Time Burden (Hours)	25,000	25,000
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This form is being created to collect the information necessary to administer the Pension program after the rule is finalized.

Annual Cost to Federal Government: $2,082,500

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? Uncollected

Agency Contact: Nancy Kessinger 202 632-8924 nancy.kessinger@va.gov

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