OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 201104-2900-028 · OMB 2900-0545 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21-8416b Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death Form Modified Repair queued
2900-0545 justification.docx Supporting Statement A Uploaded 2011-08-22 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
28721 Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death Form Modified
ICR Details
2900-0545 201104-2900-028
Historical Active 200805-2900-001
VA 2900-0545
Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death
Extension without change of a currently approved collection   No
Regular
Approved without change 01/16/2012
Retrieve Notice of Action (NOA) 09/01/2011
  Inventory as of this Action Requested Previously Approved
01/31/2015 36 Months From Approved 01/31/2012
1,500 0 1,500
1,125 0 1,125
0 0 0
VA Form 21-8416b is used to gather information about certain expenses related to securing compensation based on personal injury or death. The form is used by claimants for VA income-based benefits in order to determine the amount of countable income. Without this information, VA would be unable to properly determine entitlement to income-based benefits and the rate payable.
US Code: 38 USC 1503 Name of Law: Determinations with respect to annual income
  
None
Not associated with rulemaking
  76 FR 114 06/14/2011
76 FR 168 08/30/2011
No
  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 1,500 1,500 0 0 0 0
Annual Time Burden (Hours) 1,125 1,125 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$35,128
No
No
No
No
No
Uncollected
Denise McLamb 202-565-8374 [email protected]
  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.
09/01/2011