VA Form 21-4140 Employment Questionnaire

What Is VA Form 21-4140?

VA Form 21-4140 - or the VA Employment Questionnaire - is a form used by the Department of Veterans Affairs (VA) for gathering the information necessary to determine a Veteran's continued entitlement to Individual Unemployability benefits.

The VA released the latest edition of the form in October 2017. An up-to-date VA Form 21-4140 fillable version is available for download and digital filing below.

Individual Unemployability (IU) benefits - or Total Disability based on Individual Unemployability (TDIU) benefits - are payments provided to Veterans who are unable to secure a job due to a service-connected disability. A TDIU rating equates to a 100% disability rating. If a Veteran is granted a TDIU rating their VA service-connected disability rating is automatically raised to 100%.

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Download VA Form 21-4140 Employment Questionnaire

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VA Form 21-4140 Instructions

The VA 21-4140 must be completed annually by all IU recipients under the age of 60. The VA requires Veterans who receive IU benefits to regularly certify that they are still unemployed or marginally employed.

A step-by-step overview of all boxes on the form can be found below.

How to Fill Out VA Form 21-4140?

  1. Section I - Veteran's Identification Information - requires the Veteran to provide their full name, Social Security number, VA file number, date of birth, current mailing address and contact information.
  2. Section II - Employment Certification - requires the Veteran to list all employment over the previous year. The required information includes the names and addresses of all employers, the type of work done, the dates of employment, monthly earnings and the time lost from illness.
  3. Section III - Unemployment Certification - is signed by Veterans who were unemployed for the previous 12 months to certify that the provided information is correct and true.

Where to Mail VA Form 21-4140?

The VA has implemented centralized mail processing for all compensation claims. The mailing address for VA Form 21-4140 is:

Department of Veterans Affairs, Clams Intake Center, PO BOX 4444, JANESVILLE, WI 53547-4444

Forms can be faxed to the VA toll-free at 844-531-7818 or 248-524-4260 (for Foreign Claimants).