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

ICR 202012-2900-006

OMB: 2900-0545

Federal Form Document

ICR Details
2900-0545 202012-2900-006
Received in OIRA 201708-2900-006
Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (VA Form 21P-8416b)
Reinstatement with change of a previously approved collection   No
Regular 06/08/2021
  Requested Previously Approved
36 Months From Approved
1,500 0
1,125 0
28,935 0

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.

US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income

Not associated with rulemaking

  86 FR 14686 03/17/2021
86 FR 28932 05/28/2021

  Total Request 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 0 0 0 0 1,500
Annual Time Burden (Hours) 1,125 0 0 0 0 1,125
Annual Cost Burden (Dollars) 28,935 0 0 2,092 0 26,843

Maribel Aponte 202 266-4688 [email protected]


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:
    (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;
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.

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