VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability

What Is VA Form 21-8940?

VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability is a form released by the Department of Veteran Affairs (VA) and submitted in order to get a Total Disability Individual Unemployability (TDIU) benefit. The TDIU program allows a veteran to be compensated as 100% disabled, despite the fact that service-connected disabilities may not be equivalent to a 100% disability.

The form - also known as the VA TDIU Form or Total Disability/Individual Unemployability - was released by the VA in October 2017 and is available for download below.

People usually apply for the program when their service-connected disabilities stop them from performing a substantially gainful activity. This program is a very powerful tool for a veteran, allowing them to live on a sustainable income when their service-connected conditions, illness, injuries or disability prevent a veteran from working.

Filling out and submitting the VA Form 21-8940 allows you to avoid a denial. Usually, when you see the phrase "your claim for TDIU is administratively denied" it means you simply did not complete the form.

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OMB Approved No. 2900-0404
Respondent Burden: 45 minutes
Expiration Date:10/31/2020
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)
VETERAN'S APPLICATION FOR INCREASED
COMPENSATION BASED ON UNEMPLOYABILITY
NOTE: This is a claim for compensation benefits based on unemployability. When you complete this form you are claiming
total disability because of a service-connected disability(ies) which has/have prevented you from securing or following any
substantially gainful occupation. Answer all questions fully and accurately. See mail/fax information on page 3 of this form.
Social Security Benefits: Individuals who have a disability and meet medical criteria may qualify for Social Security of Supplemental
Security Income disability benefits. If you would like more information about Social Security benefits, contact your nearest Social
Security Administration (SSA) office. You can locate the address of the nearest SSA office in your telephone book blue pages under
"United States Government, Social Security Administration" or call 1-800-772-1213 (Hearing Impaired TDD line 1-800-325-0778.).
You may also contact SSA by Internet at http://www.ssa.gov/.
SECTION I - VETERAN IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly to expedite processing the form.
1. NAME OF VETERAN (FIRST, MIDDLE INITIAL, LAST)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
4. DATE OF BIRTH (MM,DD,YYYY)
Month
Day
Year
(No. and street or rural route, city or P.O., State, ZIP Code and Country)
5. MAILING ADDRESS OF VETERAN
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
(Include Area Code)
7. TELEPHONE NUMBER
(If applicable)
6. EMAIL ADDRESS
SECTION II - DISABILITY AND MEDICAL TREATMENT
8. WHAT SERVICE-CONNECTED DISABILITY PREVENTS
10. DATE(S) OF TREATMENT BY DOCTOR(S)
9. HAVE YOU BEEN UNDER A DOCTOR'S CARE
YOU FROM SECURING OR FOLLOWING ANY
AND/OR HOSPITALIZED WITHIN THE PAST 12
FROM
TO
SUBSTANTIALLY GAINFUL OCCUPATION?
MONTHS?
YES
NO
12. NAME AND ADDRESS OF HOSPITAL
13. DATE(S) OF HOSPITALIZATION
11. NAME AND ADDRESS OF DOCTOR(S)
FROM
TO
SECTION III - EMPLOYMENT STATEMENT
14. DATE YOUR DISABILITY AFFECTED
16. DATE YOU BECAME TOO DISABLED TO WORK
15. DATE YOU LAST WORKED FULL-TIME
FULL-TIME EMPLOYMENT
Day
Year
Month
Day
Year
Month
Year
Month
Day
17A. WHAT IS THE MOST YOU EVER EARNED IN ONE YEAR?
17B. WHAT YEAR?
17C. OCCUPATION DURING THAT YEAR
Year
$
VA FORM
21-8940
SUPERSEDES VA FORM 21-8940, FEB 2016,
Page 1
OCT 2017
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0404
Respondent Burden: 45 minutes
Expiration Date:10/31/2020
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)
VETERAN'S APPLICATION FOR INCREASED
COMPENSATION BASED ON UNEMPLOYABILITY
NOTE: This is a claim for compensation benefits based on unemployability. When you complete this form you are claiming
total disability because of a service-connected disability(ies) which has/have prevented you from securing or following any
substantially gainful occupation. Answer all questions fully and accurately. See mail/fax information on page 3 of this form.
Social Security Benefits: Individuals who have a disability and meet medical criteria may qualify for Social Security of Supplemental
Security Income disability benefits. If you would like more information about Social Security benefits, contact your nearest Social
Security Administration (SSA) office. You can locate the address of the nearest SSA office in your telephone book blue pages under
"United States Government, Social Security Administration" or call 1-800-772-1213 (Hearing Impaired TDD line 1-800-325-0778.).
You may also contact SSA by Internet at http://www.ssa.gov/.
SECTION I - VETERAN IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly to expedite processing the form.
1. NAME OF VETERAN (FIRST, MIDDLE INITIAL, LAST)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
4. DATE OF BIRTH (MM,DD,YYYY)
Month
Day
Year
(No. and street or rural route, city or P.O., State, ZIP Code and Country)
5. MAILING ADDRESS OF VETERAN
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
(Include Area Code)
7. TELEPHONE NUMBER
(If applicable)
6. EMAIL ADDRESS
SECTION II - DISABILITY AND MEDICAL TREATMENT
8. WHAT SERVICE-CONNECTED DISABILITY PREVENTS
10. DATE(S) OF TREATMENT BY DOCTOR(S)
9. HAVE YOU BEEN UNDER A DOCTOR'S CARE
YOU FROM SECURING OR FOLLOWING ANY
AND/OR HOSPITALIZED WITHIN THE PAST 12
FROM
TO
SUBSTANTIALLY GAINFUL OCCUPATION?
MONTHS?
YES
NO
12. NAME AND ADDRESS OF HOSPITAL
13. DATE(S) OF HOSPITALIZATION
11. NAME AND ADDRESS OF DOCTOR(S)
FROM
TO
SECTION III - EMPLOYMENT STATEMENT
14. DATE YOUR DISABILITY AFFECTED
16. DATE YOU BECAME TOO DISABLED TO WORK
15. DATE YOU LAST WORKED FULL-TIME
FULL-TIME EMPLOYMENT
Day
Year
Month
Day
Year
Month
Year
Month
Day
17A. WHAT IS THE MOST YOU EVER EARNED IN ONE YEAR?
17B. WHAT YEAR?
17C. OCCUPATION DURING THAT YEAR
Year
$
VA FORM
21-8940
SUPERSEDES VA FORM 21-8940, FEB 2016,
Page 1
OCT 2017
WHICH WILL NOT BE USED.
VETERAN'S SOCIAL SECURITY NO.
SECTION III - EMPLOYMENT STATEMENT (Continued)
18. LIST ALL YOUR EMPLOYMENT INCLUDING SELF-EMPLOYMENT FOR THE LAST FIVE YEARS YOU WORKED
(Include any military duty including inactive duty for training)
D. DATES OF EMPLOYMENT
A. NAME AND ADDRESS OF EMPLOYER
B. TYPE OF
C. HOURS
E. TIME LOST
F. HIGHEST GROSS
(OR UNIT)
WORK
PER WEEK
FROM ILLNESS
EARNINGS PER MONTH
FROM
TO
18G. IF YOU ARE CURRENTLY SERVING IN THE RESERVE OR NATIONAL GUARD, DOES YOUR SERVICE CONNECTED DISABILITY PREVENT YOU FROM
PERFORMING YOUR MILITARY DUTIES?
YES
NO
18I. IF PRESENTLY EMPLOYED, INDICATE YOUR CURRENT MONTHLY EARNED
18H. INDICATE YOUR TOTAL EARNED INCOME FOR THE PAST 12 MONTHS
INCOME
$
$
19. DID YOU LEAVE YOUR LAST JOB/SELF-EMPLOYMENT
20. DO YOU RECEIVE/EXPECT TO RECEIVE
21. DO YOU RECEIVE/EXPECT TO RECEIVE
BECAUSE OF YOUR DISABILITY?
DISABILITY RETIREMENT BENEFITS?
WORKERS COMPENSATION BENEFITS?
(If "Yes," give the facts in Item 26,
YES
NO
YES
NO
YES
NO
"Remarks")
22. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?
(If "Yes," complete Items 22A, 22B, and 22C)
YES
NO
A. NAME AND ADDRESS OF EMPLOYER
B. TYPE OF WORK
C. DATE APPLIED
SECTION IV - SCHOOLING AND OTHER TRAINING
(Check highest year completed)
23. EDUCATION
GRADE SCHOOL
1
2
3
4
5
6
7
8
HIGH SCHOOL
1
2
3
4
COLLEGE
1
2
3
4
24A. DID YOU HAVE ANY OTHER EDUCATION AND TRAINING BEFORE YOU WERE TOO DISABLED TO WORK?
(If "Yes," complete Items 24B, and 24C)
YES
NO
24C. DATES OF TRAINING
24B. TYPE OF EDUCATION OR TRAINING
BEGINNING
COMPLETION
25A. HAVE YOU HAD ANY EDUCATION AND TRAINING SINCE YOU BECAME TOO DISABLED TO WORK?
(If "Yes," complete Items 25B, and 25C)
YES
NO
25C. DATES OF TRAINING
25B. TYPE OF EDUCATION OR TRAINING
BEGINNING
COMPLETION
Page 2
VA FORM 21-8940, OCT 2017
VETERAN'S SOCIAL SECURITY NO.
26. REMARKS (If any)
SECTION IV - AUTHORIZATION, CERTIFICATION, AND SIGNATURE
AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the person or entity, including but not limited to any organization, service provider, employer, or
Government agency, to give the Department of Veterans Affairs any information about me except protected health information, and I waive any privilege which makes the
information confidential.
CERTIFICATION OF STATEMENTS: I CERTIFY THAT as a result of my service-connected disabilities, I am unable to secure or follow any substantially gainful
occupation and that the statements in this application are true and complete to the best of my knowledge and belief. I understand that these statements will be considered in
determining my eligibility for VA benefits based on unemployability because of service-connected disability.
I UNDERSTAND THAT IF I AM GRANTED SERVICE-CONNECTED TOTAL DISABILITY BENEFITS BASED ON MY UNEMPLOYABILITY, I MUST IMMEDIATELY INFORM
VA IF I RETURN TO WORK.
I ALSO UNDERSTAND THAT TOTAL DISABILITY BENEFITS PAID TO ME AFTER I BEGIN WORK MAY BE CONSIDERED AN
OVERPAYMENT REQUIRING REPAYMENT TO VA.
(Do Not Print) (Sign in ink)
27. SIGNATURE OF CLAIMANT
28. DATE SIGNED
WITNESS TO SIGNATURE OF CLAIMANT IF MADE "X" MARK. NOTE: Signature made by mark must be witnessed by two persons to whom the person making the
statement is personally know and the signature and address of such witnesses must be shown below.
(Sign in ink)
29A. SIGNATURE OF WITNESS
29B. ADDRESS OF WITNESS
(Sign in ink)
30B. ADDRESS OF WITNESS
30A. SIGNATURE OF WITNESS
SECTION V - WHERE TO SEND CORRESPONDENCE
MAIL TO:
FAX TO:
Department of Veterans Affairs
844-531-7818 (Toll Free) OR
Evidence Intake Center
Local: 248-524-4260
PO Box 4444
Janesville, WI 53547-4444
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 the 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
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. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under
Title 38, U.S.C. 5101(c)(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior
to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits provided 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 your eligibility for compensation. Title 38, United States Code, allows us to ask for this information. We estimate that you
will need an average of 45 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 3
VA FORM 21-8940, OCT 2017

Download VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability

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VA Form 21-8940 and 21-4192

The benefits to all military personnel physically challenged due to service-connected medical conditions are given by the VA. To receive the status of a challenged person a veteran has to go through the VA Disability Process. The best way to do this is within a year of the date of separation from the military. You may also be eligible for a VA Disability Back Pay, to make up for the time between the date of eligibility and the VA rating decision. In the case of leaving the army for medical reasons, the VA Disability Process starts automatically.

After the claim is submitted, the VA begins the process with the Compensation and Pension Exam (C&P Exam) to check the physical status of the veteran.

A veteran is also eligible to claim Individual Unemployability if they are unable to maintain a regular income. Anything that pays less than the amount established by the Department of Commerce does not count as a regular income. In this case, a VA Form 21-8940 should be submitted and sent to the VA.

After you start the process, your past employers will receive a VA Form 21-4192 in order to verify your employment history, the dates of employment and your reasons for leaving their place of work. The statement of a service-connected disability may be supported with evidence provided by a doctor.

VA Form 21-8940 Instructions

The 21-8940 may be one of the hardest VA applications to fill out. Usually, the main filling guidelines can be found inside the form, and some filling out tips and instructions can be found below.

Get VA Form 21-8940 help and filing advice through the VA hotline at 1-800-827-1000.

How to Fill out VA Form 21-8940

  1. Section I (Boxes 6-11). Box 6 answer what service-connected disability prevents you from working;
  2. Section II (Boxes 12-20). Answer when your disability started. Generally, it is sufficient to indicate the month and the year;
  3. Box 16. Enter the names and addresses of the places/companies you worked for. If this information is missing, the VA will send a notice requesting the information;
  4. The question about receiving or expecting to receive Disability Retirement benefits includes any Social Security benefits, such as SSD and SSI.

Where to Mail VA Form 21-8940?

Once the form is completed, it should be mailed to the VA Evidence Intake Center (PO Box 4444, Janesville, WI 53547-4444) or faxed to 844-531-7818 (Toll Free) or 248-524-4260 (Local).

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