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Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident (21P-4176)

IC 28285 under ICR 201405-2900-002 · OMB 2900-0104.

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Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident (21P-4176) 2900-0104 VBA-P&F-DB
 
No Modified
 
Required to Obtain or Retain Benefits
 
38 CFR 3.301

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 21P-4176 Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident 21P-4176.pdf http://www.va.gov/vaforms/ Yes No Fillable Printable

General Government Legislative Functions

 

4,408 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,408 0 0 0 0 4,408
Annual IC Time Burden (Hours) 2,204 0 0 0 0 2,204
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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