Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (VA Form 21P-8416b)

Forms and Documents

Document Name	Status
Form VA Form 21P-8416b Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b) Form	Modified
2900-0545 30-Day FRN.pdf Supplementary Document	2017-12-19
2900-0545 60-Day FRN.pdf Supplementary Document	2017-10-12
2900-0545 Supporting Statement.docx Supporting Statement A	2017-12-12

IC Document Collections

IC ID	Document Title	Status
28721	Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b) Form	Modified

ICR Details

OMB Control No: 2900-0545	ICR Reference No: 201708-2900-006
Status: Active	Previous ICR Reference No: 201404-2900-010
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-NK
Title: Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (VA Form 21P-8416b)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/05/2018
	Date Received in OIRA: 12/27/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved	03/31/2018
Responses	1,500	0	1,500
Time Burden (Hours)	1,125	0	1,125
Cost Burden (Dollars)	26,843	0	0

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Abstract: VA Form 21P-8416b is used to gather information about certain expenses related to securing compensation based on personal injury or death. The form is used by claimants for VA income-based benefits in order to determine the amount of countable income. Without this information, VA would be unable to properly determine entitlement to income-based benefits and the rate payable.

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Authorizing Statute(s): US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 22056	10/12/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 60278	12/19/2017
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b)	VA Form 21P-8416b	Report of Medical, Legal and Other Expenses Incident to Recovery ofr Injury or Death

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,500	1,500	0	0	0	0
Annual Time Burden (Hours)	1,125	1,125	0	0	0	0
Annual Cost Burden (Dollars)	26,843	0	0	26,843	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $53,835

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/27/2017

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