Approved for use
through 6/2002 under the condition that the VA immediately
incorporates the disclosure statements mandated pursuant to the
Paperwork Reduction Act of 1995. For the public record, the VA must
submit to OMB the revised forms/instructions.
Inventory as of this Action
Requested
Previously Approved
06/30/2002
06/30/2002
2,400
0
0
800
0
0
0
0
0
38 U.S.C. 103 requires that marital
status be clarified before benefits may be paid to or for a spouse.
VAF 21-4171 is used to gather the necessary information from
individuals who know the relationship which existed between
parties, in those cases in which a common law marriage is
claimed.
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:
(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;
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.