2900-0545 justification

Supporting Statement for VA Form 21-8416b

Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death

(2900-0545)

A. Justification

1. The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. A claimant’s eligibility for pension is determined, in part, by countable family income. Information is requested by this form under the authority of 38 U.S.C. 1503. Regulatory authority is found in 38 C.F.R. 3.262, 3.271, and 3.272.

2. VA Form 21-8416b is used to gather information that is necessary to determine eligibility for income-based benefits and the rate payable. When a claimant is awarded compensation by another entity or government agency based on personal injury or death, the compensation is usually countable income for VA purposes (38 CFR 3.262(i)). However, medical, legal or other expenses incident to the injury or death, or incident to the collection or recovery of the compensation, may be deducted from the amount of the award or settlement (38 CFR 3.271(g) and 3.272(g)). VA From 21-8416b is used to report these expenses.

3. VA Form 21-8416b is available on the One-VA web site in a fillable electronic format. VBA is currently hosting the form on a secure server and does not currently have technology in place to allow for complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the forms to be incorporated with an existing centralized legacy database. Veterans Online Applications (VONAPP) allows applicants to view, print, and submit applications electronically to VBA. However, VA Form 21-8416b is not one of the forms scheduled to be added to VONAPP because estimated total usage of this form is low. The Department will reconsider adding this form to VONAPP when the resources become available or if usage of this form becomes greater.

4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our department.

5. The collection of information does not involve small businesses or entities.

6. This form solicits information that is necessary to determine the amount of deductible expenses a claimant paid related to monetary recovery for personal injury or death. Without this information, VA would be unable to authorize and properly pay income-based benefits.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in the Federal Register on June 14, 2011, page 34812. No comments were received.

9. No payments or gifts to respondents will be made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22/28,‘‘Compensation, Pension, Education, and Rehabilitation Records—VA ’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 1,500 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 1,125 hours.

d. The estimated completion time of 45 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $16,875 (1,125 hours x $15 per hour).

13. This submission does not involve any record keeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $34,878

(GS-12/5 @ 40.66 x 1,500 x 10/60 minutes = $ 10,165)

(GS-9/5 @ $28.04 x 1,500 x 30/60 minutes = $21,031)

(GS-3/5 @ $14.73 x 1,500 x 10/60 minutes = $ 3,682)

b. Printing and production cost $250

c. Total cost to government $35,128

15. There are no changes to the burden hours of this form

16. The information collection is not for publication or tabulation use.

17. The collection instrument, VA Form 21-8416b, may be reproduced and/or stocked by the respondents and veterans service organizations. This VA form does not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of this form. This form is submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action on the benefit being sought. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA continues to seek an exemption that waives the displaying of the expiration date on VA Form 21-8416b.

18. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

This submission does not collect information employing statistical methods.