VA Form 21-4192, Request for Employment Information in Connection With Claim for Disability Benefits is a document used by the Department of Veterans 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.
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 VA Form 21-8940 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.