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Notice

Agency Information Collection Activity Under OMB Review: Income Verification

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AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995, this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden; it includes the actual data collection instrument.

DATES:

Comments must be submitted on or before May 4, 2017.

ADDRESSES:

Submit written comments on the collection of information through www.Regulations.gov, or to Office of Information and Regulatory Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 17th St. NW., Washington, DC 20503 or sent through electronic mail to oira_submission@omb.eop.gov. Please refer to “OMB Control No. 2900-NEW” in any correspondence.

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FOR FURTHER INFORMATION CONTACT:

Cynthia Harvey-Pryor, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 461-5870 or email cynthia.harvey-pryor@va.gov. Please refer to “OMB Control No. 2900-NEW.”

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SUPPLEMENTARY INFORMATION:

Titles:

a. Mailed with Veterans' Initial Letters—HEC Form 200-1A

b. Mailed with Spouses' Initial Letters—HEC Form 220-1

c. Mailed to Veterans When Necessary—HEC Form 340-1

d. Mailed to Veterans When Necessary—Checklist

OMB Control Number: 2900-NEW.

Type of Review: New collection.

Abstract:

The HEC, IVD uses HEC Form 200-1A (Veteran's Income Verification Response) to collect income verification information, as applicable, from the Veteran by requesting the Veteran to verify the listed income on the form as reported to IVD by IRS/SSA, to select the appropriate option on the form Start Printed Page 16475relating to the household income, attest to out of pocket medical expenses, attest to sale of primary home real estate and attest to separation from spouse for the income year under the Income Verification Division's review. The Veteran's signature is required on page 2 of HEC Form 200-1A. If the Veteran has medical/health limitations that does not enable the Veteran to physically sign the form with a wet signature, the Veteran must mark an “X” to designate a signature; two witnesses must verify the “X” as the Veteran's signature. HEC, IVD will use the completed HEC Form 200-1A to assist in verifying the Veteran's correct gross household income to ensure the Veteran is placed in the correct priority group for health care.

The HEC, IVD uses HEC Form 220-1 (Spouse's Income Verification Response) to collect income verification information, as applicable, from the Veteran's spouse by requesting the spouse to verify the listed income on the form as reported to IVD by IRS/SSA, report any additional income not reported by IRS/SSA and sign and date the form. If the spouse has medical/health limitations that does not enable the spouse to physically sign the form with a wet signature, the spouse must mark an “X” to designate a signature; two witnesses must verify the “X” as the Veteran's signature. HEC, IVD will use the completed HEC Form 220-1 to assist in verifying the Veteran's correct gross household income to ensure the Veteran is placed in the correct priority group for health care.

The HEC, IVD uses the HEC Form 340-1 (Declaration of Representative) for the Veteran and the spouse (if applicable) to appoint a representative, authorizing HEC, IVD to release information to a designated appointee for a specific income year. Such information includes confidential federal tax information, other income, and medical benefits eligibility related information. The Veteran and spouse (if applicable) must sign and date the form.

The HEC, IVD uses the HEC Income Verification—Additional Information Checklist to request from the Veteran any additional information needed to adjudicate the Income Verification case. The Veteran providing the requested information usually results in the best interest to the Veteran.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published at 82 FRN 8566-8567 on January 26, 2017.

Affected Public: Individuals or households.

Estimated Annual Burden:

a. Mailed with Veterans' Initial Letters—HEC Form 200-1A—89,001 hours

b. Mailed with Spouses' Initial Letters—HEC Form 220-1—28,530 hours

c. Mailed to Veterans When Necessary—HEC Form 340-1—1,701 hours

d. Mailed to Veterans When Necessary—Checklist—761 hours

Estimated Average Burden Per Respondent:

a. Mailed with Veterans' Initial Letters—HEC Form 200-1A—30 minutes

b. Mailed with Spouses' Initial Letters—HEC Form 220-1—20 minutes

c. Mailed to Veterans When Necessary—HEC Form 340-1—15 minutes

d. Mailed to Veterans When Necessary—Checklist—761—15 minutes

Frequency of Response: Annually.

Estimated Annual Responses:

a. Mailed with Veterans' Initial Letters—HEC Form 200-1A—178,002

b. Mailed with Spouses' Initial Letters—HEC Form 220-1—85,590

c. Mailed to Veterans When Necessary—HEC Form 340-1—6,805

d. Mailed to Veterans When Necessary—Checklist—761—3,044

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Authority: 44 U.S.C. 3501-3521

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By direction of the Secretary.

Cynthia Harvey-Pryor,

Department Clearance Officer, Enterprise Records Service, Office of Quality and Compliance, Department of Veterans Affairs.

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[FR Doc. 2017-06573 Filed 4-3-17; 8:45 am]

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