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Federal forms, ICRs, and supporting documents

OMB control number

Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193)

OMB 2900-0116 · VA.

OMB 2900-0116

VA Form 21-4193 is used to gather information from penal institutions about incarcerated VA beneficiaries. When beneficiaries are incarcerated in penal institutions in excess of 60 days after conviction, VA benefits are reduced or terminated. Without this collection of information, VA would be unable to accurately adjust the rates of incarcerated beneficiaries and overpayments would result.

The latest form for Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution (VA Form 21-4193) expires 2028-12-31 and can be found here.

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Name
Form
Supplementary Document
Supplementary Document
Supporting Statement A
All Historical Document Collections
 Revision of a currently approved collection 2025-08-28
Approved without change
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Approved without change
 Extension without change of a currently approved collection 2017-06-30
Approved without change
 Revision of a currently approved collection 2014-03-21
Approved without change
 Extension without change of a currently approved collection 2011-01-03
Approved without change
 Extension without change of a currently approved collection 2008-01-07
Approved without change
 Extension without change of a currently approved collection 2005-05-11
Approved without change
 Extension without change of a currently approved collection 2002-03-29
Approved without change
 Reinstatement without change of a previously approved collection 1999-07-12
Withdrawn and continue
 Extension without change of a currently approved collection 1995-08-28
Approved without change
 Extension without change of a currently approved collection 1993-07-01
Approved without change
 Extension without change of a currently approved collection 1990-08-10
Approved with change
 No material or nonsubstantive change to a currently approved collection 1989-05-05
Approved without change
 Extension without change of a currently approved collection 1987-09-28
Approved without change
 Reinstatement with change of a previously approved collection 1984-11-09
Approved without change
 Revision of a currently approved collection 1983-11-25
Approved with change
 No material or nonsubstantive change to a currently approved collection 1981-02-19
Approved without change
 Revision of a currently approved collection 1980-12-22
Approved with change
 No material or nonsubstantive change to a currently approved collection 1980-11-06
Approved without change
 Revision of a currently approved collection 1977-11-15