Information Collection

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

IC 28721 under ICR 202012-2900-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 21P-8416b Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b) Form
VA Form 21P-8416b Report of Medical, Legal and Other Expenses Incident to 21P-8416b(10-10-17).pdf www.va.gov/vaforms Form
VA Form 21P-8416b Report of Medical, Legal and Other Expenses Incident to 21P-8416b(10-10-17).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 (21P-8416b)	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 3.262 38 CFR 3.272 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 21P-8416b	Report of Medical, Legal and Other Expenses Incident to Recovery ofr Injury or Death	21P-8416b(10-10-17).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)	FR Citation: 77 FR 42593

Number of Respondents: 1,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,500	0	1,500
Annual IC Time Burden (Hours)	1,125	0	1,125
Annual IC Cost Burden (Dollars)	28,935	2,092	26,843

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.