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

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

Documents and Forms

Document Name Document Type
Form 21P-8416b Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b) Form
21P-8416b Report of Medical, Legal, and Other Expenses Incident to VA Form 21P-8416b -New Burden Statement (508 Conformant 6-20-23) 3-28-24.pdf www.va.gov/vaforms Form
21P-8416b Report of Medical, Legal, and Other Expenses Incident to VA Form 21P-8416b -New Burden Statement (508 Conformant 6-20-23) 3-28-24.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

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	21P-8416b	Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death	VA Form 21P-8416b -New Burden Statement (508 Conformant 6-20-23) 3-28-24.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: 84 FR 38

Number of Respondents: 100	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	Previously Approved
Annual Number of Responses for this IC	100	-1,400	1,500
Annual IC Time Burden (Hours)	75	-1,050	1,125
Annual IC Cost Burden (Dollars)	2,232	-26,703	28,935

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.