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:
2900-0867
ICR Reference No:
202501-2900-009
Status:
Active
Previous ICR Reference No:
202010-2900-006
Agency/Subagency:
VA
Agency Tracking No:
VHA-2900-0867
Title:
Health Eligibility Center (HEC) Income Verification (IV) Forms
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:
07/28/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/23/2025
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
07/31/2028
36 Months From Approved
07/31/2025
Responses
117,109
0
122,789
Time Burden (Hours)
48,338
0
49,758
Cost Burden (Dollars)
0
0
0
Abstract:
VHA Directive 1909 provides policy for the Department of Veterans Affairs (VA) Health Eligibility Center (HEC) Income Verification (IV) Program under authority of 38 United States Code (U.S.C.) 1722; 38 U.S.C. 5317. Title 38 U.S.C. 1722 established eligibility assessment procedures, based on income levels, for determining whether nonservice-connected (NSC) Veterans and non-compensable zero percent service-connected (SC) Veterans, who have no other special eligibility are eligible to receive Department of Veterans Affairs (VA) health care at no cost. Title 26 U.S.C. 6103 (l)(7) of the Internal Revenue Code, and 38 U.S.C. 5317 establish authority for VA to verify Veterans’ gross household income information against records maintained by the Internal Revenue Service (IRS) and Social Security Administration (SSA) when that information indicates the Veteran is eligible for cost-free VA health care. In accordance with VHA Directive 1909, it is VA policy that the Health Eligibility Center (HEC) is responsible for the Income Verification Program, i.e., verifying NSC and non-compensable zero percent SC Veterans’ gross household income through computer matching activity with IRS and SSA. The social security numbers (SSNs) of all Veterans and their spouses identified in the financial assessment will be verified under the Social Security Number Verification Information Exchange Agreement (IEA), between the SSA and VHA HEC, prior to income matching activity with IRS. If IRS and SSA income matching identifies discrepancies in the Veteran’s self-reported gross household income information that potentially impacts eligibility for VA health care benefits, HEC must independently verify the IRS and SSA income data. If the Veteran’s eligibility for VA health care benefits is changed as a result of the income verification process, HEC will transmit the updated eligibility information to those facilities that provided health services to the Veteran during the applicable income-reporting period. HEC’s Income Verification Division (IVD) sends Veterans and spouses individual letters and forms to confirm income information reported by IRS and SSA. HEC does not change the Veteran’s copay status until information supplied by IRS and SSA has been independently verified, either by the Veteran or through appropriate due process procedures. This collection has been revised by removing VA Form 10-302A because all relevant information can be reported on VA Form 10-302. There is a reduction in the burden hours due to the removal of VA Form 10-302A from the collection.
Authorizing Statute(s):
US Code:
38 USC 5317
Name of Law: Use of income information from other agencies
US Code:
26 USC 6103
Name of Law: Confidentiality and disclosure of returns and return information
US Code:
38 USC 1722
Name of Law: Determination of Income Thresholds
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:
90 FR 16596
04/18/2025
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 26679
06/23/2025
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
4
IC Title
Form No.
Form Name
Declaration of Representative
10-303
Declaration of Representative
IRS-SSA Spouse Reported Income
10-302
IRS-SSA Spouse Reported Income
IRS-SSA Veteran Reported Income
10-301
IRS-SSA Veteran Reported Income
Spouse Additional Income
10-302a
Spouse Additional Income
Waiver Statement
10-304
Waiver Statement
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
117,109
122,789
0
-5,680
0
0
Annual Time Burden (Hours)
48,338
49,758
0
-1,420
0
0
Annual Cost Burden (Dollars)
0
0
0
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:
Changing Forms
Short Statement:
There is a reduction in the burden hours due to the removal of VA Form 10-302A from the collection.
Annual Cost to Federal Government:
$185,449
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:
Frances O'Donnell 703 405-2449 fran.odonnell@cathexiscorp.com
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:
06/23/2025
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