VA · Official form

VA Form 21-4192: Request for Employment Information in Connection with Claim for Disability Benefits

VA Form 21-4192 is completed by a veteran's employer, not the veteran. It gives VA the employment facts needed to decide an Individual Unemployability (TDIU) claim.

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What is VA Form 21-4192?

VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, asks an employer to report a veteran's dates of employment, type of work, hours, earnings, time lost due to disability, concessions made because of disability, and the reason employment ended. VA sends it to employers when a veteran applies for Individual Unemployability benefits on VA Form 21-8940.

The employer's answers help VA verify whether service-connected disabilities prevent the veteran from maintaining substantially gainful employment. The current edition is dated August 2024. If an employer does not return the form, VA can still decide the claim on the other evidence of record, but a completed form usually speeds the decision.

Who files VA Form 21-4192?

Employers, current or former, of veterans claiming Individual Unemployability
HR departments and payroll offices responding to a VA request for employment details
Veterans forwarding the form to recent employers to speed up a TDIU claim
Reserve or Guard units reporting drill status for a member with a pending claim

How to fill out VA Form 21-4192

Enter the veteran's name, Social Security number, and VA file number in the identification block.
The employer completes the employment details: dates worked, type of work, hours per week, and earnings for the last 12 months of employment.
Report any time lost due to disability, concessions made to the employee, and the date and reason employment ended, if it has.
An authorized company official signs and dates the certification with their title and contact information.
Return the form to VA: upload it through va.gov or mail it to the VA Claims Intake Center address in the instructions.

Worth knowing: This form is completed and signed by the employer. Veterans applying for Individual Unemployability start with VA Form 21-8940.

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These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to VA.

Page 1 41 fields

1. NAME AND ADDRESS OF EMPLOYER OF VETERAN (Complete).

RETURN TO. 2. ADDRESS (Complete).

Read Instructions above. SECTION 1 - IDENTIFICATION INFORMATION. Read Note above. 3. VETERAN / BENEFICIARY'S NAME (First, Middle Initial,

3. VETERAN / BENEFICIARY'S NAME. Enter Middle Initial. 1 character max.

3. VETERAN / BENEFICIARY'S NAME. Enter Last Name. 18 characters max.

4. SOCIAL SECURITY NUMBER. Enter First Three Digits.

4. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

4. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

5. V. A. FILE NUMBER (If applicable). Enter 9 digit file number.

6. DATE OF BIRTH. Enter 2 digit Month.

6. DATE OF BIRTH. Enter 2 digit Day.

6. DATE OF BIRTH. Enter 4 digit Year.

SECTION 2 - EMPLOYMENT INFORMATION (To be completed by employer). 7. BEGINNING DATE OF EMPLOYMENT. Enter 2 digit Month.

7. BEGINNING DATE OF EMPLOYMENT. Enter 2 digit Day.

7. BEGINNING DATE OF EMPLOYMENT. Enter 4 digit Year.

8. ENDING DATE OF EMPLOYMENT. Enter 2 digit Month.

8. ENDING DATE OF EMPLOYMENT. Enter 2 digit Day.

8. ENDING DATE OF EMPLOYMENT. Enter 4 digit Year.

9. TYPE OF WORK PERFORMED.

10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT (Before Deductions). Enter first 3 digits.

10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT (Before Deductions). Enter last 3 digits.

10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT (Before Deductions). Enter 2 digit cents.

11. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT (DUE TO DISABILITY).

12. A. NUMBER OF HOURS WORKED (Daily). 3 digits max.

12B. NUMBER OF HOURS WORKED (Weekly). 3 digits max.

13. CONCESSIONS (if any) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY.

14. A. IF VETERAN IS NOT WORKING, STATE THE REASON FOR TERMINATION OF EMPLOYMENT (If retired on disability, please specify).

14B. DATE LAST WORKED. Enter 2 digit Month.

14B. DATE LAST WORKED. Enter 2 digit Day.

14B. DATE LAST WORKED. Enter 4 digit Year.

15. A. DATE OF LAST PAYMENT. Enter 2 digit Month.

15. A. DATE OF LAST PAYMENT. Enter 2 digit Day.

15. A. DATE OF LAST PAYMENT. Enter 4 digit Year.

15B. GROSS AMOUNT OF LAST PAYMENT. Enter dollar amount.

16. A. WAS LUMP SUM PAYMENT MADE? YES.

16. A. GROSS AMOUNT PAID. Enter dollar amount.

16B. DATE PAID. Enter 2 digit Month.

16B. DATE PAID. Enter 2 digit Day.

16B. DATE PAID. Enter 4 digit Year.

SECTION 3 - RESERVE OR NATIONAL GUARD DUTY STATUS (Only complete if claimant is currently serving in the Reserve or National Guard). 17. A.

17B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES? YES.

Page 2 16 fields

SECTION 4 - INFORMATION ON BENEFIT ENTITLEMENT AND / OR PAYMENTS (To be completed by employer). 18. IS VETERAN RECEIVING OR ENTITLED TO

19. TYPE OF BENEFIT.

20. GROSS MONTHLY AMOUNT OF BENEFIT. Enter first 3 digits.

20. GROSS MONTHLY AMOUNT OF BENEFIT. Enter last 3 digits.

20. GROSS MONTHLY AMOUNT OF BENEFIT. Enter 2 digit cents.

21. A. DATE BENEFIT BEGAN. Enter 2 digit Month.

21. A. DATE BENEFIT BEGAN. Enter 2 digit Day.

21. A. DATE BENEFIT BEGAN. Enter 4 digit Year.

21B. DATE FIRST PAYMENT ISSUED. Enter 2 digit Month.

21B. DATE FIRST PAYMENT ISSUED. Enter 2 digit Day.

21B. DATE FIRST PAYMENT ISSUED. Enter 4 digit Year.

21C. DATE BENEFIT WILL STOP (If known). Enter 2 digit Month.

21C. DATE BENEFIT WILL STOP (If known). Enter 2 digit Day.

21C. DATE BENEFIT WILL STOP (If known). Enter 4 digit Year.

22. REMARKS.

23B. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.

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Frequently asked questions

Does the veteran fill out VA Form 21-4192?

No. The veteran completes VA Form 21-8940 to apply for Individual Unemployability; the 21-4192 is completed by each employer the veteran worked for, typically covering the last year of employment. Veterans can help by giving the form to the employer with the identification block filled in.

What happens if my former employer will not return the form?

VA will make reasonable attempts to get it, but a missing 21-4192 does not automatically sink the claim. VA can decide TDIU based on the rest of the evidence, including your own statements, medical records, and Social Security records.

Which employers get this form?

Generally the employers the veteran listed on the 21-8940 for the period since becoming too disabled to work, most importantly the last employer. Each employer completes its own copy.

VA Form 21-4192: Request for Employment Information in Connection with Claim for Disability Benefits

What is VA Form 21-4192?

Who files VA Form 21-4192?

How to fill out VA Form 21-4192

Quick fill VA Form 21-4192 on this page

Frequently asked questions

Related forms

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

VA Form 21-526EZ, Application for Disability Compensation

VA Form 21-4138: Statement in Support of Claim