Items 1 to 5: Veteran identification
The Veteran's name, Social Security number, VA file number, date of birth and service number, if applicable.
21P-8416b
Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death
- Agency
- VA
- Revision
- June 2024
- Fillable fields
- 168
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21P-8416b: Report of Medical, Legal and Other Expenses Incident to Recovery
VA Form 21P-8416b is the U.S. Department of Veterans Affairs Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death. The form's note says that if you or a family member received compensation for injury, illness or death, the date and amount of the recovery are to be reported to VA, and that in most instances the amount received will be countable income for VA purposes. It adds that the amount counted can be reduced by any unreimbursed expenses incurred in connection with the recovery, and that this form is used to report those expenses.
The form is two pages. Part I identifies the Veteran and the claimant, Part II is a table of expenses that continues on page 2, and the claimant signs a certification at the end. VA's form page lists it under burials and memorials. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21P-8416b
Items 6 to 9: claimant and contact details
The claimant's name if other than the Veteran, the current mailing address, a telephone number and an optional email address.
Item 10: explanation of expenses
A table with the purpose, such as legal fees, fees for expert witnesses or medical expenses paid before the date of recovery, the amount paid by you, the date paid, the name of the provider and who paid the compensation, such as the RR Retirement Board or a civil lawsuit.
Page 2 continuation
Item 10 continues on page 2 for more expenses, with a line for the Veteran's SSN at the top of the page.
Items 11 and 12: certification and signature
A certification that the information is true, the claimant's signature in ink in Item 11 and the date signed in Item 12.
Penalty and privacy notices
Page 2 states the penalty for willfully submitting false statements or evidence, the Privacy Act information and a respondent burden of 45 minutes.
How to fill out VA Form 21P-8416b
- 1
Read page 2 first
The instructions say to read the Privacy Act and Respondent Burden information on page 2 before completing the form.
- 2
Fill in Part I
Enter the Veteran's and claimant's details. The form says it can be completed online or by hand, printing in blue or black ink, neatly and legibly.
- 3
List each expense
Use the Item 10 table to give the purpose, amount paid, date paid, provider and who paid the compensation for each expense, continuing on page 2 when needed.
- 4
Sign and date it
The claimant signs Item 11 in ink and enters the date in Item 12.
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Sending it and other details
Mailing address
Neither the form nor VA's form page prints a mailing address for VA Form 21P-8416b.
Online
VA's form page offers the form as a downloadable PDF and lists no online version.
Social Security number
The Privacy Act notice says giving your SSN is voluntary and that refusal to provide it by itself will not result in the denial of benefits.
Edition
The June 2024 edition supersedes the July 2021 edition, which the form says will not be used. It carries OMB Control No. 2900-0545, which expires 06/30/2027.
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Who uses VA Form 21P-8416b?
The form names who it identifies, who signs it and who receives it.
Official sources and the blank
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Questions about Form 21P-8416b
What is VA Form 21P-8416b used for?
The form's note says it is used to report the unreimbursed medical, legal and other expenses incurred in connection with a recovery for injury, illness or death, which can reduce the amount VA counts as income.
What kinds of expenses does the form list?
Column A of Item 10 gives examples: legal fees, fees for expert witnesses and medical expenses paid before the date of recovery. Column D names providers such as a doctor, attorney or consultant.
Who signs VA Form 21P-8416b?
The claimant signs Item 11 in ink and dates Item 12, certifying that the information is true.
What if the expenses do not fit on page 1?
The Item 10 table continues on page 2 of the form.
Can I fill out the form on a computer?
Yes. The form says it can be completed online or by hand, and asks for blue or black ink when it is completed by hand.
How long does the form take?
The respondent burden notice estimates an average of 45 minutes per respondent, per year.