Reginfo. gov/public/do/PRAMain. If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM FEB 2012 21P-8416 SUPERSEDES VA FORM 21P-8416 DEC 2011 WHICH WILL NOT BE USED. I certify that the above information is true. 22A. SIGNATURE OF CLAIMANT Do NOT print 22B. DATE 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. VA FORM 21P-8416 FEB 2012. We will let you know if an expense cannot be allowed. You may be asked to verify the amounts you actually paid so keep all receipts or other documentation of payments for at lease 3 years after we make a decision on your medical expense claim. If you are unable to provide documentation of the claimed medical expenses when asked to do so by VA your benefits may be retroactively reduced or terminated. If more space is needed to report expenses attach a separate sheet of paper with columns corresponding to those on this form. Be sure to write your VA file number on any attachments. RESPONDENT BURDEN We need this information to determine whether medical expenses you paid may be used to reduce the amount of income we count in determining eligibility to benefits 38 U.S.C. 1503. Title 38 United States Code allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www. NOTE If you claim miles traveled to a medical facility in a personal conveyance car motorcycle other VA will calculate the allowable expense amount based on the current mileage rate 41. 5 cents per mile. A. MEDICAL FACILITY TO WHICH YOU TRAVELED B. TOTAL ROUNDTRIP C. AMOUNT PAID BY YOU Taxi public transportation fares MILES TRAVELED Personal conveyance only tolls parking fees etc. D. DATE PAID Month/Day/Year E. FOR WHOM PAID Self spouse child IMPORTANT Be sure to sign this form in Item 22A on the reverse side. If no dates appear on this line refer to the accompanying letter or Eligibility Verification Report for the dates you should report medical expenses. NOTE If you claim miles traveled to a medical facility in a personal conveyance car motorcycle other VA will calculate the allowable expense amount based on the current mileage rate 41. 5 cents per mile. A. MEDICAL FACILITY TO WHICH YOU TRAVELED B. TOTAL ROUNDTRIP C. AMOUNT PAID BY YOU Taxi public transportation fares MILES TRAVELED Personal conveyance only tolls parking fees etc. D. DATE PAID Month/Day/Year E. FOR WHOM PAID Self spouse child IMPORTANT Be sure to sign this form in Item 22A on the reverse side. Unsigned reports will be returned. Continued on Reverse Report medical expenses that you paid between the dates the accompanying letter or Eligibility Verification Report for the dates you should report medical expenses. Hospital Charges Eyeglasses Oxygen Rental Medical Insurance etc. BY YOU D. NAME OF PROVIDER Name of doctor dentist hospital lab etc. MEDICARE PART B PRIVATE MEDICAL INSURANCE CERTIFICATION I have not and will not receive reimbursement for these expenses. 5 cents per mile. A. MEDICAL FACILITY TO WHICH YOU TRAVELED B. TOTAL ROUNDTRIP C. AMOUNT PAID BY YOU Taxi public transportation fares MILES TRAVELED Personal conveyance only tolls parking fees etc. D. DATE PAID Month/Day/Year E. FOR WHOM PAID Self spouse child IMPORTANT Be sure to sign this form in Item 22A on the reverse side. Unsigned reports will be returned. Continued on Reverse Report medical expenses that you paid between the dates the accompanying letter or Eligibility Verification Report for the dates you should report medical expenses.
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Video instructions and help with filling out and completing medical expense report va form 21 8416

Hi there looks like you've got an accounting coming do this video is the second in a set of three videos which explain steps in completing your annual accounting this video will give you instructions on how to complete the income section of your accounting for more information on the other steps in the accounting process see our other videos before you begin your accounting which discusses the steps you should take to prepare for your accounting and how to complete your accounting part 2 which discusses how to complete the expenses section and finalize all accounting actions before we begin you should have gathered all bank statements and any other pertinent information also if required you should have a completed VA Form 21p — 47 18a remember most fiduciaries won't need to complete that form now let's get into how to complete your accounting using VA form 21 P — 4706 B federal fiduciaries account let's start with the basics first you'll need a pen I know that might sound silly but by law this accounting form cannot be completed in pencil if you're more comfortable using a computer electronic copies of this document can be found at the website here the web address is also located on your accounting request letter now let's get into the nuts and bolts let's look at the section called money received this will be where you document the money you've received from the VA on behalf of the beneficiary first let's talk total estate at beginning of period if this is your first accounting that's easy put 0 even if you are informally handling the beneficiary's funds before you're appointed as fiduciary for VA purposes you began handling the VA funds under management on the day you're appointed if this is not your first accounting the beginning estate should match the ending estate from the previous accounting check the last accounting that was approved by VA and look at block size in the second column right above remarks your beginning balance should exactly match that number now let's take a look at income there's a couple sections here first amount received from VA when documenting VA income take a look at your bank statements and keep track of what was deposited by VA throughout the accounting period you'll enter the number of months and the amount for those months for example let's say the beneficiary received an increase in benefits halfway through the year in this case the beneficiary was receiving $2,000 per month from January through the end of June and $2,500 per month from July through December in the first line under number of months enter 6 and under monthly amount enter 2022 in the second line under number of months enter 6 and under monthly amount enter 2500 finally under the amount column enter the total for each six-month period so for the first line you'd enter $12,000 six months at $2,000 per month the amount received from.
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