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.