Information Collection

Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death

IC 28721 under ICR 200805-2900-001 · OMB 2900-0545.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0545 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-8416b Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death	Form
VA Form 21-8416b Report of Medical, Legal, and other Expenses and other E 21-8416b.pdf www.va.gov/vaforms	Form

IC Title:

Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death

Agency IC Tracking Number:

2900-0545

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.272 38 CFR 3.262 38 CFR 3.271

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-8416b	Report of Medical, Legal, and other Expenses and other Expenses Incident to Recovery for Injury or Death	21-8416b.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	1,125	1,125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.