Form VA Form 21-4192 VA Form 21-4192 Request for Employment Information in Connection with Cl

OMB Control No. 2900-0065
Respondent Burden: 15 minutes
Expiration Date: XXXXXXX

REQUEST FOR EMPLOYMENT INFORMATION
IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS
SECTION I - IDENTIFICATION INFORMATION (To be completed by VA)

.

.

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

2. ADDRESS (Complete)

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 above address.
Please be sure to sign and date this form in Items 21A and 21B. 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.
3. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN

4. SOCIAL SECURITY NO.

5. VA FILE NO.

SECTION II - EMPLOYMENT INFORMATION (To be completed by employer)
6. BEGINNING DATE OF
EMPLOYMENT

7. ENDING DATE OF
EMPLOYMENT

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

8. AMOUNT EARNED DURING 12 MONTHS PRECEDING
LAST DATE OF EMPLOYMENT (BEFORE DEDUCTIONS)

$
10. TYPE OF WORK PERFORMED

11. NUMBER OF HOURS WORKED
A. DAILY

B. WEEKLY

12. CONCESSIONS (IF ANY) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY

13A. IF VETERAN IS NOT WORKING, STATE REASON FOR TERMINATION OF
EMPLOYMENT. IF RETIRED ON DISABILITY, PLEASE SPECIFY

13B. DATE LAST
WORKED

14A. DATE OF LAST PAYMENT

14B. GROSS AMOUNT OF LAST PAYMENT

$
15A. WAS LUMP SUM PAYMENT MADE?

15B. GROSS AMOUNT PAID

15C. DATE PAID

(If "Yes," complete Items 15B and 15C)
$
YES
NO
SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS (Only complete if claimant is currently serving in the Reserve or National Guard)
16A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?

16B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING
THEIR MILITARY DUTIES?

NO
YES
SECTION IV - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS (To be completed by employer)
17. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE, AS A RESULT OF
HIS/HER EMPLOYMENT WITH YOU, SICK, RETIREMENT OR OTHER
BENEFITS?

YES

NO

18. TYPE OF BENEFIT

(If "Yes," complete Items 18 through 20C)

19. GROSS MONTHLY AMOUNT OF BENEFIT

20A. DATE BENEFIT
BEGAN

20B. DATE FIRST PAYMENT
ISSUED

20C. DATE BENEFIT WILL STOP (If known)

21A. SIGNATURE OF EMPLOYER OR SUPERVISOR (If claimant is serving in the Reserves or National Guard, then signature of unit commander
or designee is required)

21B. DATE

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.
SUPERSEDES VA FORM 21-4192, DEC 2010,
VA FORM
WHICH WILL NOT BE USED.
XXX 2014

21-4192