21P-8416b Report of Medical, Legal, and Other Expenses Incident to

OMB Control No. 2900-0545
Respondent Burden: 45 Minutes
Expiration Date: XX/XX/20XX

REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT
TO RECOVERY FOR INJURY OR DEATH

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

INSTRUCTIONS: Read the Privacy Act and Respondent Burden Information on Page 2 before completing the form.
NOTE: If you or a family member received compensation for injury, illness or death, you must report the date and
amount of the recovery to VA. In most instances, the amount received will be countable income for VA purposes.
However, the amount counted in determining your entitlement to VA benefits can be reduced by the amount of any
unreimbursed expenses incurred in connection with the recovery. Use this form to report those expenses.

PART I - PERSONAL IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S SERVICE NUMBER (If applicable)

6. CLAIMANT'S NAME (First, Middle Initial, Last) (If other than veteran)

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

8. TELEPHONE NUMBER (Include Area Code)

9. EMAIL ADDRESS (Optional)

PART II - EXPLANATION OF EXPENSES
10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death.
A. PURPOSE (Legal Fees, Fees for

Expert Witnesses, Medical Expenses
Paid Before Date of Recovery, etc.)

VA FORM
XXX XXXX

21P-8416b

B. AMOUNT PAID
BY YOU

C. DATE PAID

(MM/DD/YYYY)

SUPERSEDES VA FORM 21P-8416b, JUL 2021,
WHICH WILL NOT BE USED.

D. NAME OF PROVIDER

(Doctor, Attorney,
Consultant, etc.)

E. COMPENSATION
PAID BY

(RR Retirement Board,
Civil Lawsuit, etc.)

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VETERAN'S SSN:
10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death. (Continued)
A. PURPOSE (Legal Fees, Fees for
Expert Witnesses, Medical Expenses
Paid Before Date of Recovery, etc.)

B. AMOUNT PAID
BY YOU

C. DATE PAID

(MM/DD/YYYY)

D. NAME OF PROVIDER

(Doctor, Attorney,
Consultant, etc.)

E. COMPENSATION
PAID BY

(RR Retirement Board,
Civil Lawsuit, etc.)

I CERTIFY THAT the above information is true.
11. SIGNATURE OF CLAIMANT (Sign in ink)

12. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations

1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a
party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28,
Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your response is required to obtain or retain benefits. The requested information is considered
relevant and necessary to determine maximum benefits under the law. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving
us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure
of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification
through computer matching programs with other agencies.

RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0545, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 45 minutes
per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports
Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0545 in any correspondence. Do not send your completed VA Form 21P-8416b to this email
address.
VA FORM 21P-8416b, XXX XXXX

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