Form VA Form 21-8416b VA Form 21-8416b Report of Medical, Legal, and other Expenses and other E

OMB Approved No. 2900-0545
Respondent Burden: 45 Minutes
Expiration Date: XX/XX/XXXX

REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR
DEATH

1. NAME OF VETERAN (First,middle,last)

2. VA FILE NUMBER

3B. CHANGE OF ADDRESS (Check box

3A. NAME AND ADDRESS OF CLAIMANT

if address in Item 3A is different
from last address furnished to VA)

C/CSS
4. VETERAN'S SOCIAL SECURITY NO.

NOTE: If you or a family member received compensation for injury, illness or death, you must report the date and amount of the recovery to VA.
In most instances, the amount received will be countable income for VA purposes. However, the amount counted in determining your entitlement to
VA benefits can be reduced by the amount of any unreimbursed expenses incurred in connection with the recovery. Use this form to report those
expenses.
5. EXPLANATION OF EXPENSES
A. PURPOSE (Legal Fees, Fees for
Expert Witnesses, Medical Expenses
Paid Before Date of Recovery, etc.)

B. AMOUNT PAID
BY YOU

C. DATE
PAID
(Mo/Day/Yr)

D. NAME OF PROVIDER
(Doctor, Attorney,
Consultant, etc.)

IMPORTANT: Be sure to sign this form in Item 6 on the reverse side. Unsigned reports will be returned.
VA FORM
MAY 2014

21P-8416b

SUPERSEDES VA FORM 21-8416b, AUG 2011,
WHICH WILL NOT BE USED.

E. COMPENSATION
PAID BY
(RR Retirement Board,
Civil Lawsuit, etc.)

5. EXPLANATION OF EXPENSES (Continued)
A. PURPOSE (Legal Fees, Fees for
Expert Witnesses, Medical Expenses
Paid Before Date of Recovery, etc.)

B. AMOUNT PAID
BY YOU

I CERTIFY THAT the above information is true.
6. SIGNATURE OF CLAIMANT

7. DATE

C. DATE
PAID
(Mo/Day/Yr)

D. NAME OF PROVIDER
(Doctor, Attorney,
Consultant, etc.)

E. COMPENSATION
PAID BY
(RR Retirement Board,
Civil Lawsuit, etc.)

8. TELEPHONE NUMBER(S) (Including Area Code)

A. DAYTIME

B. EVENING

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38,
Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the
collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA
benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education,
and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The
requested information is considered relevant and necessary to determine maximum benefits under the law. VA uses your SSN to identify your claim file. Providing your
SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN
by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is
required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701).
Information submitted is subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine eligibility to pension (38 U.S.C. 1503). Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection
of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid
OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on
where to send comments or suggestions about this form.
VA FORM 21-8416b, MAY 2014