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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OMB Approved No. 2900-0079
Respondent Burden: 5 minutes
Expiration Date: 10/31/2020
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)
EMPLOYMENT QUESTIONNAIRE
IMPORTANT: You are receiving compensation at the 100 percent rate based on being unable to secure or follow a
substantially gainful occupation as a result of your service-connected disabilities. Section I needs to be completed in order
to identify the person filling out the form. If you were self-employed or employed by others, including the Department of
Veterans Affairs, at any time during the past 12 months, complete Section II of this form. If you have not been employed
during the past 12 months, complete Section III of this form.
DATE MAILED
STATION
ADDRESS
SECTION I-VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information required in ink, neatly, and legibly to help process the form.
1. NAME OF VETERAN (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
5. VETERAN'S SERVICE NUMBER (If applicable)
6. E-MAIL ADDRESS (Optional)
7. PRIMARY TELEPHONE NUMBER (Include Area Code)
8. ALTERNATE TELEPHONE NUMBER (Include Area Code)
9. CURRENT MAILING ADDRESS OF VETERAN (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
10. WERE YOU EMPLOYED BY VA, OTHERS OR SELF EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS? (If "Yes,"
complete Section II only, if "No," complete Section III only)
YES
NO
SECTION II-EMPLOYMENT CERTIFICATION
List all employment for the past 12 months
11F. HIGHEST
11D. DATES OF EMPLOYMENT
11E. TIME
11A. NAME AND ADDRESS OF EMPLOYER
11B. TYPE
11C. HOURS
GROSS
OR SELF-EMPLOYMENT
LOST FROM
(If self-employed, write "self")
OF WORK
PER WEEK
EARNINGS
ILLNESS
PER MONTH
FROM
TO
VA FORM
Page 1
21-4140
OCT 2017
OMB Approved No. 2900-0079
Respondent Burden: 5 minutes
Expiration Date: 10/31/2020
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)
EMPLOYMENT QUESTIONNAIRE
IMPORTANT: You are receiving compensation at the 100 percent rate based on being unable to secure or follow a
substantially gainful occupation as a result of your service-connected disabilities. Section I needs to be completed in order
to identify the person filling out the form. If you were self-employed or employed by others, including the Department of
Veterans Affairs, at any time during the past 12 months, complete Section II of this form. If you have not been employed
during the past 12 months, complete Section III of this form.
DATE MAILED
STATION
ADDRESS
SECTION I-VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information required in ink, neatly, and legibly to help process the form.
1. NAME OF VETERAN (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
5. VETERAN'S SERVICE NUMBER (If applicable)
6. E-MAIL ADDRESS (Optional)
7. PRIMARY TELEPHONE NUMBER (Include Area Code)
8. ALTERNATE TELEPHONE NUMBER (Include Area Code)
9. CURRENT MAILING ADDRESS OF VETERAN (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
10. WERE YOU EMPLOYED BY VA, OTHERS OR SELF EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS? (If "Yes,"
complete Section II only, if "No," complete Section III only)
YES
NO
SECTION II-EMPLOYMENT CERTIFICATION
List all employment for the past 12 months
11F. HIGHEST
11D. DATES OF EMPLOYMENT
11E. TIME
11A. NAME AND ADDRESS OF EMPLOYER
11B. TYPE
11C. HOURS
GROSS
OR SELF-EMPLOYMENT
LOST FROM
(If self-employed, write "self")
OF WORK
PER WEEK
EARNINGS
ILLNESS
PER MONTH
FROM
TO
VA FORM
Page 1
21-4140
OCT 2017
VETERAN'S SOCIAL SECURITY NO.
SECTION II-EMPLOYMENT CERTIFICATION (Continued)
11F. HIGHEST
11D. DATES OF EMPLOYMENT
11E. TIME
11A. NAME AND ADDRESS OF EMPLOYER
11B. TYPE
11C. HOURS
GROSS
OR SELF-EMPLOYMENT
LOST FROM
(If self-employed, write "self")
OF WORK
PER WEEK
EARNINGS
ILLNESS
PER MONTH
FROM
TO
I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief.
I UNDERSTAND THAT my continued entitlement to VA unemployability compensation benefits will be based on information that I have furnished
on this form or that I hereafter may be required to furnish VA.
12B. DATE SIGNED (MM/DD/YYYY)
12A. SIGNATURE OF VETERAN (REQUIRED) (Sign in ink)
SECTION III-UNEMPLOYEMENT CERTIFICATION
Complete this section if you did NOT work during the past 12 months
I CERTIFY THAT I have not been employed by VA, others or self-employed during the past twelve months.
I FURTHER CERTIFY THAT the items completed on this form are true and correct to the best of my knowledge and belief. I believe that my
service-connected disability(ies) has not improved and continues to prevent me from securing or following gainful employment.
13A. SIGNATURE OF VETERAN (REQUIRED) (Sign in ink)
13B. DATE SIGNED (MM/DD/YYYY)
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 to be false, or for fraudulent acceptance of any payment to which you are not entitled.
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. 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 continued eligibility to compensation at the 100 percent rate based on individual unemployability (38
CFR 4.16). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 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
VA FORM 21-4140, OCT 2017

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).

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