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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.