View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 2900-0114	ICR Reference No: 202404-2900-005
Status: Active	Previous ICR Reference No: 202009-2900-015
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-YA
Title: Statement of Marital Relationship (VA Form 21-4170)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/12/2024
	Date Received in OIRA: 07/09/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2027	36 Months From Approved	08/31/2024
Responses	1,984	0	2,205
Time Burden (Hours)	827	0	919
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	1,984	2,205	-221
Annual Time Burden (Hours)	827	919	-92
Annual Cost Burden (Dollars)	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The respondent burden has decreased due to the estimated number of receivables averaged over the past year.

Annual Cost to Federal Government: $101,184

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 maribel.aponte@va.gov

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