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.

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OMB Control No. 2900-0065
Respondent Burden: 15 minutes
Expiration Date: 09/30/2020
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR
DISABILITY BENEFITS
(Complete)
(Complete)
2. ADDRESS
1. NAME AND ADDRESS OF EMPLOYER OF VETERAN
RETURN
TO
INSTRUCTIONS: The veteran named in Item 3 has filed a claim for veterans disability benefits and has stated that he/she was recently employed by you. In order to
arrive at a fair decision in this case, we need the information requested below. Please complete Sections II, III and IV and return to this office at the address below.
Please be sure to sign and date this form in Items 23A and 23B. For free help in completing this form, call VA toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the Federal number is 711.
SECTION I - IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
3. VETERAN/BENEFICARY'S NAME (First, Middle Initial, Last)
6. DATE OF BIRTH (MM/DD/YYYY)
4. SOCIAL SECURITY NUMBER
5. VA FILE NUMBER (If applicable)
Month
Day
Year
SECTION II - EMPLOYMENT INFORMATION (To be completed by employer)
7. BEGINNING DATE OF EMPLOYMENT (MM/DD/YYYY)
8. ENDING DATE OF EMPLOYMENT (MM/DD/YYYY)
9. TYPE OF WORK PERFORMED
Month
Day
Year
Month
Day
Year
10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF
11. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT
(DUE TO DISABILITY)
EMPLOYMENT (BEFORE DEDUCTIONS)
$
12A. NUMBER OF HOURS WORKED (Daily)
12B. NUMBER OF HOURS WORKED (Weekly)
13. CONCESSIONS (if any) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY
14A. IF VETERAN IS NOT WORKING, STATE THE REASON FOR TERMINATION OF EMPLOYMENT:
14B. DATE LAST WORKED
(IF RETIRED ON DISABILITY, PLEASE SPECIFY)
Month
Day
Year
16A. WAS LUMP SUM PAYMENT
15B. GROSS AMOUNT OF
16B. DATE PAID
15A. DATE OF LAST PAYMENT
MADE?
LAST PAYMENT
YES
NO
Month
Day
Year
Month
Day
Year
GROSS AMOUNT PAID
$
$
SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS
(Only complete if claimant is currently serving in the Reserve or National Guard)
17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?
17B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES?
YES
NO
VA FORM
SUPERSEDES VA FORM 21-4192, JUL 2015,
21-4192
SEP 2017
WHICH WILL NOT BE USED.
OMB Control No. 2900-0065
Respondent Burden: 15 minutes
Expiration Date: 09/30/2020
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR
DISABILITY BENEFITS
(Complete)
(Complete)
2. ADDRESS
1. NAME AND ADDRESS OF EMPLOYER OF VETERAN
RETURN
TO
INSTRUCTIONS: The veteran named in Item 3 has filed a claim for veterans disability benefits and has stated that he/she was recently employed by you. In order to
arrive at a fair decision in this case, we need the information requested below. Please complete Sections II, III and IV and return to this office at the address below.
Please be sure to sign and date this form in Items 23A and 23B. For free help in completing this form, call VA toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the Federal number is 711.
SECTION I - IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
3. VETERAN/BENEFICARY'S NAME (First, Middle Initial, Last)
6. DATE OF BIRTH (MM/DD/YYYY)
4. SOCIAL SECURITY NUMBER
5. VA FILE NUMBER (If applicable)
Month
Day
Year
SECTION II - EMPLOYMENT INFORMATION (To be completed by employer)
7. BEGINNING DATE OF EMPLOYMENT (MM/DD/YYYY)
8. ENDING DATE OF EMPLOYMENT (MM/DD/YYYY)
9. TYPE OF WORK PERFORMED
Month
Day
Year
Month
Day
Year
10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF
11. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT
(DUE TO DISABILITY)
EMPLOYMENT (BEFORE DEDUCTIONS)
$
12A. NUMBER OF HOURS WORKED (Daily)
12B. NUMBER OF HOURS WORKED (Weekly)
13. CONCESSIONS (if any) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY
14A. IF VETERAN IS NOT WORKING, STATE THE REASON FOR TERMINATION OF EMPLOYMENT:
14B. DATE LAST WORKED
(IF RETIRED ON DISABILITY, PLEASE SPECIFY)
Month
Day
Year
16A. WAS LUMP SUM PAYMENT
15B. GROSS AMOUNT OF
16B. DATE PAID
15A. DATE OF LAST PAYMENT
MADE?
LAST PAYMENT
YES
NO
Month
Day
Year
Month
Day
Year
GROSS AMOUNT PAID
$
$
SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS
(Only complete if claimant is currently serving in the Reserve or National Guard)
17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?
17B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES?
YES
NO
VA FORM
SUPERSEDES VA FORM 21-4192, JUL 2015,
21-4192
SEP 2017
WHICH WILL NOT BE USED.
VETERAN'S SOCIAL SECURITY NO.
SECTION IV - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS (To be completed by employer)
18. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE, AS A RESULT OF HIS/HER EMPLOYMENT WITH YOU, SICK, RETIREMENT OR OTHER BENEFITS?
(If "Yes," complete Items 19 through 21C)
YES
NO
19. TYPE OF BENEFIT
20. GROSS MONTHLY AMOUNT OF BENEFIT
$
(If known)
21C. DATE BENEFIT WILL STOP
21A. DATE BENEFIT BEGAN (MM/DD/YYYY)
21B. DATE FIRST PAYMENT ISSUED (MM/DD/YYYY)
(MM/DD/YYYY)
Month
Day
Year
Month
Day
Year
Month
Day
Year
22. REMARKS
I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief.
(If claimant is serving in the Reserves or National Guard,
23B. DATE SIGNED (MM/DD/YYYY)
23A. SIGNATURE OF EMPLOYER OR SUPERVISOR
then signature of unit commander or designee is required.) (Sign in ink)
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence
of a meterial 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 voluntary. 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 eligibility for disability benefits based on unemployability (38 U.S.C. 1521).
Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 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.
VA FORM 21-4192, SEP 2017
Page 2

Download VA Form 21-4192 Request for Employment Information in Connection With Claim for Disability Benefits

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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:

  1. 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;
  2. Section II should be completed by the employer and includes the veteran's employment information;
  3. 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;
  4. 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;
  5. Any concessions were made to the employee based on age or disability should be listed in box 13;
  6. If the veteran is not working, enter the reason for termination of employment and the date they last worked (boxes 14A and 14B );
  7. 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;
  8. 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;
  9. 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;
  10. 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.

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