View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
2900-0095
ICR Reference No:
201902-2900-003
Status:
Historical Active
Previous ICR Reference No:
201604-2900-009
Agency/Subagency:
VA
Agency Tracking No:
VBA-P&F-YA
Title:
Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/12/2019
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/02/2019
Terms of Clearance:
Approval is granted on the condition that VA submit a non-substantive change request within 45 days of issuance of the NOA that modifies "Your obligation to respond is required to obtain or retain benefits" to "Your response is required to obtain or retain benefits" in the Privacy Act statement and removes the requirement that the witnesses in Section V be personally known to the claimant.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2022
36 Months From Approved
12/31/2019
Responses
2,075
0
2,075
Time Burden (Hours)
1,038
0
1,038
Cost Burden (Dollars)
0
0
20,988
Abstract:
VA Form 21P-4165 (Formerly VA Form 21-4165) is used to gather information which is necessary to determine a claimant's countable annual income and available assets related to farm operations. Eligibility to income-based benefits cannot be determined without complete income information.
Authorizing Statute(s):
US Code:
38 USC 1521
Name of Law: Veterans of a period of war
US Code:
38 USC 1541
Name of Law: Surviving spouses of veterans of a period of war
US Code:
38 USC 1542
Name of Law: Children of veterans of a period of war
US Code:
38 USC 1503
Name of Law: Determinations with respect to annual income
US Code:
38 USC 1522
Name of Law: Net worth limitation
US Code:
38 USC 1543
Name of Law: Net worth limitation
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:
84 FR 11166
03/25/2019
30-day Notice:
Federal Register Citation:
Citation Date:
84 FR 25338
05/31/2019
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
Pension Claim Questionnaire for Farm Income
21P-4165
Pension Claim Questionnaire for Farm Income
ICR Summary of Burden
Total Approved
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
2,075
2,075
0
0
0
0
Annual Time Burden (Hours)
1,038
1,038
0
0
0
0
Annual Cost Burden (Dollars)
0
20,988
0
-20,988
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$57,301
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:
Danny Green 202 421-1354 danny.green2@va.gov
Common Form ICR:
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:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
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.
Certification Date:
07/02/2019
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