SUPERSEDES VA FORM 21P-8416b, MAY 2014,WHICH WILL NOT BE USED.21P-8416b

VA FORM MAR 2018

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.

REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR DEATH

OMB Approved No. 2900-0545 Respondent Burden: 45 Minutes Expiration Date: 03/31/2021

INSTRUCTIONS: Read the Privacy Act and Respondent Burden Information on Page 2 before completing the form.

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form.

PART I - PERSONAL INDENTIFICATION INFORMATION

1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER2. VETERAN'S SOCIAL SECURITY NUMBER

6. CLAIMANT'S NAME (First, Middle Initial, Last) (If other than veteran)

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

4. DATE OF BIRTH (MM/DD/YYYY)

YearDayMonth

5. VETERAN'S SERVICE NUMBER (If applicable)

No. & Street

Apt./Unit Number City

ZIP Code/Postal Code State/Province Country

PART II - EXPLANATION OF EXPENSES10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death.

A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etc.)

B. AMOUNT PAID BY YOU

C. DATE PAID

(Mo/Day/Yr)

D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etc.)

E. COMPENSATION PAID BY

(RR Retirement Board, Civil Lawsuit, etc.)

8. TELEPHONE NUMBER (Include Area Code) 9. EMAIL ADDRESS (Optional)

Page 1

10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death. (Continued)

A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etc.)

E. COMPENSATION PAID BY

(RR Retirement Board, Civil Lawsuit, etc.)

D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etc.)

C. DATE PAID

(Mo/Day/Yr)B. AMOUNT PAID

BY YOU

VA FORM 21P-8416b, MAR 2018

Veteran's SSN

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.

12. DATE SIGNED11. SIGNATURE OF CLAIMANT (Sign in ink)I CERTIFY THAT the above information is true.

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The 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 SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN 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 required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. Respondent Burden: We need this information to determine eligibility to pension (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 45 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.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.

Page 2

FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.

www.reginfo.gov/public/do/PRAMain

SUPERSEDES VA FORM 21P-8416b, MAY 2014,WHICH WILL NOT BE USED.

21P-8416b

VA FORMMAR 2018

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.

REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENTTO RECOVERY FOR INJURY OR DEATH

OMB Approved No. 2900-0545Respondent Burden: 45 Minutes

Expiration Date:  03/31/2021

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg

Department of Veterans Affairs Logo.

  INSTRUCTIONS: Read the Privacy Act and Respondent Burden Information on Page 2 before 

  completing the form.

INSTRUCTIONS: Read the Privacy Act and Respondent Burden Information on Page 2 before completing the form.

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

 NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form.

PART I - PERSONAL INDENTIFICATION INFORMATION

1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER

2. VETERAN'S SOCIAL SECURITY NUMBER

6. CLAIMANT'S NAME (First, Middle Initial, Last) (If other than veteran)

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

4. DATE OF BIRTH (MM/DD/YYYY)

Year

Day

Month

5. VETERAN'S SERVICE NUMBER (If applicable)

  No. &

  Street

Apt./Unit Number

  City

ZIP Code/Postal Code

State/Province

Country

PART II - EXPLANATION OF EXPENSES

PART 2 - EXPLANATION OF EXPENSES

10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death.

A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses   

Paid Before Date of Recovery, etc.)

B. AMOUNT PAIDBY YOU

C. DATE 

   PAID    (Mo/Day/Yr)

D. NAME OF PROVIDER(Doctor, Attorney, 

Consultant, etc.)

E. COMPENSATION PAID BY(RR Retirement Board, 

Civil Lawsuit, etc.)

8. TELEPHONE NUMBER (Include Area Code)

9. EMAIL ADDRESS (Optional)

Page 1

10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death. (Continued)

5. Current Mailing Address (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

5. Current Mailing Address (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses   

Paid Before Date of Recovery, etc.)

E. COMPENSATION PAID BY(RR Retirement Board, 

Civil Lawsuit, etc.)

D. NAME OF PROVIDER(Doctor, Attorney, 

Consultant, etc.)

C. DATE 

   PAID    (Mo/Day/Yr)

B. AMOUNT PAIDBY YOU

VA FORM 21P-8416b, MAR 2018

Veteran's SSN

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.

12. DATE SIGNED

11. SIGNATURE OF CLAIMANT (Sign in ink)

I CERTIFY THAT the above information is true.

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The 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 SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN 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 required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

Respondent Burden: We need this information to determine eligibility to pension (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 45 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.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.

Page 2

FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.

REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENTTO RECOVERY FOR INJURY OR DEATH 21P-8416b

REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR DEATH

10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 1 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 1 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 1 of 30: 10. B. AMOUNT PAID BY YOU. Line 1 of 30: PART 2 - EXPLANATION OF EXPENSES. 10. Report all medical expenses that you or a family member incurred for which you received VA compensation. 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 1 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 2 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 2 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 2 of 30: 10. B. AMOUNT PAID BY YOU. Line 2 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 2 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 3 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 3 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 3 of 30: 10. B. AMOUNT PAID BY YOU. Line 3 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 3 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 4 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 4 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 4 of 30: 10. B. AMOUNT PAID BY YOU. Line 4 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 4 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 5 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 5 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 5 of 30: 10. B. AMOUNT PAID BY YOU. Line 5 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 5 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 6 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 6 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 6 of 30: 10. B. AMOUNT PAID BY YOU. Line 6 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 6 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 7 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 7 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 7 of 30: 10. B. AMOUNT PAID BY YOU. Line 7 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 7 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 10 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 10 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 10 of 30: 10. B. AMOUNT PAID BY YOU. Line 10 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 10 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 11 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 11 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 11 of 30: 10. B. AMOUNT PAID BY YOU. Line 11 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 11 of 30.: 4. Veteran's Date of Birth. Enter 2 digit Month. : 4. Veteran's Date of Birth. Enter 2 digit day.: 4. Veteran's Date of Birth. Enter 4 digit year.: 5. Veteran's Service Number (If applicable). Enter 9 digits.: PART 1. PERSONAL IDENTIFICATION INFORMATION. NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form. 1. Veteran's Name - Enter First Name.: 1. Veteran's Name - Enter Last Name.: 1. Veteran's Name - Enter Middle Initial.: Veteran's Social Security Number - Enter first three numbers.: Veteran's Social Security Number - Enter middle two numbers.: Veteran's Social Security Number - Enter last four numbers.: 3. V. A. File Number. Enter nine digit file number.: 6. Claimant's Name (First, middle initial, last) (If other than veteran) - Enter First Name.: 6. Claimant's Name - Enter Last Name.: 6. Claimant's Name - Enter Middle Initial.: 7. Current Mailing Address. Enter Number and Street.: 7. Enter Apartment or Unit Number.: 7. Enter City.: 7. Enter State or Province.: 7. Enter Country.: 7. Enter ZIP or Postal Code. First 5 digits.: 7. Enter ZIP or Postal Code. Enter last 4 digits.: 9. ENTER EMAIL ADDRESS (Optional): 8. Enter Telephone Number (Include Area Code). : 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 19 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 19 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 19 of 30: 10. B. AMOUNT PAID BY YOU. Line 19 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 19 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 20 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 20 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 20 of 30: 10. B. AMOUNT PAID BY YOU. Line 20 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 20 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 21 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 21 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 21 of 30: 10. B. AMOUNT PAID BY YOU. Line 21 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 21 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 22 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 22 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 22 of 30: 10. B. AMOUNT PAID BY YOU. Line 22 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 22 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 23 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 23 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 23 of 30: 10. B. AMOUNT PAID BY YOU. Line 23 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 23 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 24 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 24 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 24 of 30: 10. B. AMOUNT PAID BY YOU. Line 24 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 24 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 25 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 25 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 25 of 30: 10. B. AMOUNT PAID BY YOU. Line 25 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 25 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 12 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 12 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 12 of 30: 10. B. AMOUNT PAID BY YOU. Line 12 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 12 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 13 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 13 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 13 of 30: 10. B. AMOUNT PAID BY YOU. Line 13 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 13 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 14 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 14 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 14 of 30: 10. B. AMOUNT PAID BY YOU. Line 14 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 14 of 30.: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 15 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 15 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 15 of 30: 10. B. AMOUNT PAID BY YOU. Line 15 of 30: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 16 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 16 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 16 of 30: 10. B. AMOUNT PAID BY YOU. Line 16 of 30: 10. E. COMPENSATION PAID BY (RR Retirement Board, Civil Lawsuit, etcetera). Line 18 of 30: 10. D. NAME OF PROVIDER (Doctor, Attorney, Consultant, etcetera). Line 18 of 30: 10. C. DATE PAID (Month/Day/Year) Enter 2-digit month, 2-digit day and 4-digit year. Line 18 of 30: 10.B. AMOUNT PAID BY YOU. Line 18 of 30: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 15 of 30.: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 16 of 30.: 10. A. PURPOSE (Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etcetera) line 18 of 30.: I CERTIFY THAT the above information is true. 12. DATE SIGNED. Enter 2-digit month, 2-digit day and 4-digit year.: