OMB2900-0545(21-8416b)(8-27-14)

Supporting Statement for VA Form 21P-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. The expiration date is being added to the form. The form was transferred from Compensation Service to Pension and Fiduciary Service. Due to a change in business lines, the prefix on the form has been changed from 21 to 21P.

2. VA Form 21P-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 21P-8416b is used to report these expenses.

3. VA Form VA Form 21P-8416b is available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the 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 form to be incorporated with an existing centralized legacy database.

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 12, 2014, Volume 79, No. 113, pages 33815-33816. No comments were received in response to this notice.

9. No payments or gifts to respondents have been made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22, "Compensation, Pension, Education and Rehabilitation Records - VA" as set forth in Privacy Act Issuances, 2001 compilation.

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents: 1,500

b. Frequency of Response: Once for most beneficiaries

c. Annual Burden Hours: 1,125 hours

d. Estimated Completion Time: 45 Minutes

e. According to the U.S. Bureau of Labor Statistics Average Hourly Earnings, the cost to the respondent is $24, making the total cost to the respondents an estimated $27,000. (1,125 burden hours x $24 per hour).

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

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $32,504

(GS-12/5 @ $37.89 x 1,500 x 10/60 minutes = $ 9,473)

(GS-9/5 @ $26.13 x 1,500 x 30/60 minutes = $19,598)

(GS-3/5 @ $13.73 x 1,500 x 10/60 minutes = $ 3,433)

b. Printing and production cost $0.00

c. Total cost to government $32,504

15. There is no change in respondent burden. The expiration date is being added to the form.

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 The information collection is not for publication or tabulation use.

17. We are not seeking approval to omit the expiration date for OMB approval.

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

B. Collection of Information Employing Statistical Methods

This collection of information does not employ statistical methods.