Va Form 21-8416b - Report Of Medical, Legal, And Other Expenses Incident To Recovery For Injury Or Death

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OMB Approved No. 2900-0545
Respondent Burden: 45 minutes
REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR
DEATH
First,middle,last)
2. VA FILE NUMBER
1. NAME OF VETERAN (
C/CSS
(Check box
3A. NAME AND ADDRESS OF CLAIMANT
3B. CHANGE OF ADDRESS
4. VETERAN'S SOCIAL SECURITY NO.
if address in Item 3A is different
from last address furnished to VA)
NOTE: If you or a family member received compensation for injury, illness or death, you must report the date and amount of the recovery to VA.
In most instances, the amount received will be countable income for VA purposes. However, the amount counted in determining your entitlement to
VA benefits can be reduced by the amount of any unreimbursed expenses incurred in connection with the recovery. Use this form to report those
expenses.
5. EXPLANATION OF EXPENSES
E. COMPENSATION
A. PURPOSE (Legal Fees, Fees for
C. DATE
D. NAME OF PROVIDER
B. AMOUNT PAID
PAID BY
Expert Witnesses, Medical Expenses
PAID
(Doctor, Attorney,
BY YOU
(RR Retirement Board,
Paid Before Date of Recovery, etc.)
(Mo/Day/Yr)
Consultant, etc.)
Civil Lawsuit, etc.)
IMPORTANT: Be sure to sign this form in Item 6 on the reverse side. Unsigned reports will be returned.
VA FORM
21-8416b
EXISTING STOCKS OF VA FORM 21-8416b, JUL 2005,
AUG 2011
WILL BE USED.

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