[Federal Register Volume 82, Number 63 (Tuesday, April 4, 2017)]
[Notices]
[Pages 16474-16475]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-06573]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-NEW]


Agency Information Collection Activity Under OMB Review: Income 
Verification

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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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 
[email protected]. Please refer to ``OMB Control No. 2900-
NEW'' in any correspondence.

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 
[email protected]. Please refer to ``OMB Control No. 2900-
NEW.''

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

[[Page 16475]]

relating 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

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


    By direction of the Secretary.
Cynthia Harvey-Pryor,
Department Clearance Officer, Enterprise Records Service, Office of 
Quality and Compliance, Department of Veterans Affairs.
[FR Doc. 2017-06573 Filed 4-3-17; 8:45 am]
 BILLING CODE 8320-01-P