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Federal forms, ICRs, and supporting documents

Information Collection Request

Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death

ICR 199508-2900-063 · OMB 2900-0545 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
148399 Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death Form Migrated
ICR Details
2900-0545 199508-2900-063
Historical Active 199308-2900-009
VA
Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death
Revision of a currently approved collection   No
Regular
Approved without change 09/21/1995
Retrieve Notice of Action (NOA) 08/28/1995
  Inventory as of this Action Requested Previously Approved
09/30/1998 09/30/1998 10/31/1995
10,000 0 0
7,500 0 7,500
0 0 0
VA form 21-8416b is used to report expenses incident to a monetary recovery for injury or death by a beneficiary of one of VA's income-based benefit programs. These expenses may be excluded from otherwise countable income in determining the correct rate of VA benefits.
None
None
No
1
IC Title Form No. Form Name
Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death VA-21-8416B
  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 10,000 0 0 10,000 0 0
Annual Time Burden (Hours) 7,500 7,500 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.
08/28/1995