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Federal forms, ICRs, and supporting documents

Information Collection Request

REQUEST FOR INFORMATION CONCERNING MEDICAL, LEGAL OR OTHER EXPENSES

ICR 198908-2900-004 · OMB 2900-0161 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
147374 REQUEST FOR INFORMATION CONCERNING MEDICAL, LEGAL OR OTHER EXPENSES Form Migrated
ICR Details
2900-0161 198908-2900-004
Historical Active 198608-2900-007
VA
REQUEST FOR INFORMATION CONCERNING MEDICAL, LEGAL OR OTHER EXPENSES
Extension without change of a currently approved collection   No
Regular
Approved without change 10/26/1989
Retrieve Notice of Action (NOA) 08/24/1989
  Inventory as of this Action Requested Previously Approved
10/31/1992 10/31/1992 10/31/1989
56,400 0 56,400
11,280 0 11,280
0 0 0
THIS FORM IS FOR COLLECTING MEDICAL AND/OR LEGAL EXPENSES PAID IN CONNECTION WITH CLAIMS FOR PENSION OR OTHER INCOME BASED BENEFITS. THESE EXPENSES MAY BE EXCLUDED FROM COUNTABLE INCOME IN DETERMINING THE CORRECT RATE OF VA BENEFIT PAYMENT.
None
None
No
1
IC Title Form No. Form Name
REQUEST FOR INFORMATION CONCERNING MEDICAL, LEGAL OR OTHER EXPENSES 21-8416
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 56,400 56,400 0 0 0 0
Annual Time Burden (Hours) 11,280 11,280 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/24/1989