VA Form 21-4192 Request for Employment Information in Connection With Claim for Disability Benefits
What Is VA Form 21-4192 Used for?
VA Form 21-4192, Request for Employment Information in Connection With Claim for Disability Benefits is a document used by the Department of Veteran 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 in September 2017 and supersedes the July 2015 edition. An up-to-date VA Form 21-4192 fillable version is available for digital filing and download below or can be found on the VA website.
The data required by the form is considered relevant and confidential. However, an employer's need to respond is voluntary. Willful submission of false statement or evidence may result in fine or imprisonment.
VA Form 21-4192 and 21-8940
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 the 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 the 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.
Download VA Form 21-4192 Request for Employment Information in Connection With Claim for Disability Benefits
How to Fill Out VA Form 21-4192
Filling guidelines for the VA 21-4192 are not provided in the form. Detailed step-by-step instructions can be found below.
VA Form 21 4192 Instructions
The VA Form 21-4192 includes four sections. It can be filled out online or manually. All the necessary information should be printed neatly and legibly in ink if filing a printed-out form. Filing instructions are as follows:
- Section I. Enter your personal identifying information, including your full name, Social Security Number, VA file number, and date of birth (boxes 3, 4, 5, and 6). Box 1 is designed for the name and address of the employer the veteran has indicated in their unemployability claim. Item 2 should contain a return-to address;
- Section II should be completed by the employer and includes the veteran's employment information;
- Boxes 7 and 8 require beginning and end dates of the employment period. The type of work performed should be described in box 9. Box 10 should contain the sum earned over 12 months before the last employment date;
- Box 11. Enter the time lost due to disability over the last 12 months. The employer must enter the number of hours worked by the veteran daily and weekly in boxes 12A and 12B;
- Any concessions were made to the employee based on age or disability should be listed in box 13;
- If the veteran is not working, enter the reason for termination of employment and the date they last worked (boxes 14A and 14B );
- Enter the date of the last payment and its gross amount in boxes 15A and 15B. If the payment was a lump sum, the gross amount paid and the date of payment should be entered in boxes 16A and 16B;
- Section III. Complete only if the claimant is in the Reserves or National Guard. Otherwise, skip it. The section should include the current duty status of the veteran and the information about any disabilities that prevent them from performing military duties;
- Section IV. Enter information on benefit entitlements and payments. If the veteran is receiving or entitled to receive health-related, retirement, or other benefits, the corresponding box should be ticked in box 18. In case of a positive answer, the employer will have to provide details in boxes 19 through 21C;
- Any additional remarks should be entered in box 22. The employer or supervisor needs to sign and date the document.
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. The Federal number for the individuals who use a Telecommunications Device for the Deaf (TDD) is 711.
VA 21-4192 FAQ
How important is VA Form 21-4192?
The document is important for 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.
Why did the VA send me and my employer 21-4192?
After receiving the VA 21-8940 application, the VA 21-4192 will be sent to the veteran's employers by the VA official to verify the employment history. If the employer does not respond, the VA will send a second notice to the veteran, requesting that they attempt to contact the past employer and ask them to fill out the document.
Who should sign VA Form 21-4192?
The document should be signed in ink by an employer or supervisor. If the claimant is serving in the National Guard or Reserves, the paper requires the signature of unit commander or designee.
Where do I send VA Form 21-4192?
The completed form should be sent to the address indicated in box 2 of the form.