VA Form 21-4192, Request for Employment Information in Connection With Claim for Disability Benefits, is a document used by the U.S. Department of Veterans Affairs (VA) to request the information necessary to determine if a veteran is eligible to receive disability benefits based on unemployability.
The latest version of the form was released on July 1, 2021. An up-to-date VA Form 21-4192 fillable version is available for digital filing and download below.
How important is VA Form 21-4192? The document plays a vital part in gathering and forwarding the necessary information to the VA. However, if the document is not received by the VA, the claim will not be automatically denied and will be evaluated based on the limited data provided. The data required by the form is considered relevant and confidential. Willful submission of false statements or evidence may result in fines or imprisonment.
VA Form 21-4192 FAQ
Q: Who should sign VA Form 21-4192?
A: The document should be signed in ink by an employer or supervisor. If the claimant is serving in the National Guard or Reserves, VA Form 21-4192 will require the signature of the unit commander or designee.
Q: Where do I send VA Form 21-4192?
A: The completed form should be sent to the address indicated in Box 2 of the form.
Military personnel with work limitations associated with their Army service are eligible for certain benefits. The veteran needs to go through the VA Disability Process to gain access to these benefits. During the course of this procedure, each veteran is assigned a VA Disability Rating which determines the amount of the benefits they may be eligible for. Individual Unemployability is an exception to the Total Rating rules and allows a veteran to be rated as 100% disabled if they are unable to maintain a regular, steady income.
It is necessary to submit VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to apply for Individual Unemployability. The document is used to claim total disability compensation because service-connected physical limitations prevent the veteran from following any substantially gainful occupation.
After receiving the application, the VA will send VA Form 21-4192 to the current and previous employers listed in Box 16A to verify the fact and dates of employment, to provide the reason for termination of the employment, etc. However, it is the veteran's responsibility to make sure the document is completed and returned to the VA.
All the necessary information should be printed neatly and legibly in ink (if filing a printed-out form). VA Form 21-4192 instructions are as follows:
If the employer experiences any difficulties with filling out the form, they can call the VA toll-free at +1 (800) 827-1000 for help.