Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193)

OMB 2900-0116

VA Form 21-4193 is used to gather information from penal institutions about incarcerated VA beneficiaries. When beneficiaries are incarcerated in penal institutions in excess of 60 days after conviction, VA benefits are reduced or terminated. Without this collection of information, VA would be unable to accurately adjust the rates of incarcerated beneficiaries and overpayments would result.

The latest form for Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193) expires 2020-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form VA 21-4193 Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193) Form
30-Day FRN.pdf Supplementary Document
2022-14966, 60-Day FRN (2900-0116).pdf Supplementary Document
2900-0116, Supporting Statement (VAF21-4193).docx Supporting Statement A
Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193) Form

All Historical Document Collections

202207-2900-001 Approved without change	Reinstatement with change of a previously approved collection	2022-09-19
201612-2900-015 Approved without change	Extension without change of a currently approved collection	2017-06-30
201307-2900-015 Approved without change	Revision of a currently approved collection	2014-03-21
201009-2900-016 Approved without change	Extension without change of a currently approved collection	2011-01-03
200709-2900-021 Approved without change	Extension without change of a currently approved collection	2008-01-07
200505-2900-006 Approved without change	Extension without change of a currently approved collection	2005-05-11
200203-2900-011 Approved without change	Extension without change of a currently approved collection	2002-03-29
199907-2900-004 Approved without change	Reinstatement without change of a previously approved collection	1999-07-12
199508-2900-042 Withdrawn and continue	Extension without change of a currently approved collection	1995-08-28
199307-2900-007 Approved without change	Extension without change of a currently approved collection	1993-07-01
199008-2900-003 Approved without change	Extension without change of a currently approved collection	1990-08-10
198905-2900-020 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-05-05
198709-2900-029 Approved without change	Extension without change of a currently approved collection	1987-09-28
198411-2900-004 Approved without change	Reinstatement with change of a previously approved collection	1984-11-09
198311-2900-010 Approved without change	Revision of a currently approved collection	1983-11-25
198102-2900-012 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-02-19
198012-2900-010 Approved without change	Revision of a currently approved collection	1980-12-22
198011-2900-082 Approved with change	No material or nonsubstantive change to a currently approved collection	1980-11-06
197711-2900-001 Approved without change	Revision of a currently approved collection	1977-11-15