Va Form 21-8416b - Report Of Medical, Legal, And Other Expenses Incident To Recovery For Injury Or Death Page 2

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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,

(Mo/Day/Yr)

Consultant, etc.)

Paid Before Date of Recovery, etc.)

Civil Lawsuit, etc.)

I CERTIFY THAT the above information is true.

(Including Area Code)

6. SIGNATURE OF CLAIMANT

7. DATE

8. TELEPHONE NUMBER(S)

A. DAYTIME

B. EVENING

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,

knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.

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Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the

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requested information is considered relevant and necessary to determine maximum benefits under the law. VA uses your SSN to identify your claim file. Providing your

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by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is

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estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection

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VA FORM 21-8416b, AUG 2011