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
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR
DISABILITY BENEFITS
2. ADDRESS (Complete)

1. NAME AND ADDRESS OF EMPLOYER OF VETERAN (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 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)

4. SOCIAL SECURITY NUMBER

6. DATE OF BIRTH (MM/DD/YYYY)

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)
Month

Day

8. ENDING DATE OF EMPLOYMENT (MM/DD/YYYY) 9. TYPE OF WORK PERFORMED

Year

Month

Day

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

Year

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

$
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:
(IF RETIRED ON DISABILITY, PLEASE SPECIFY)

14B. DATE LAST WORKED
Month

15B. GROSS AMOUNT OF
LAST PAYMENT

15A. DATE OF LAST PAYMENT
Month

Day

16A. WAS LUMP SUM PAYMENT
MADE?
YES

Year

Month

$

17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?

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

VA FORM
XXXXX

NO

21-4192

SUPERSEDES VA FORM 21-4192, JUL 2015,
WHICH WILL NOT BE USED.

Day

Year

16B. DATE PAID

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

YES

Year

NO

GROSS AMOUNT PAID

$

Day

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?
YES

NO

(If "Yes," complete Items 19 through 21C)

19. TYPE OF BENEFIT

20. GROSS MONTHLY AMOUNT OF BENEFIT

$
21A. DATE BENEFIT BEGAN (MM/DD/YYYY)
Month

Day

Year

21B. DATE FIRST PAYMENT ISSUED (MM/DD/YYYY)
Month

Day

Year

21C. DATE BENEFIT WILL STOP (If known)

(MM/DD/YYYY)
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.
23A. SIGNATURE OF EMPLOYER OR SUPERVISOR (If claimant is serving in the Reserves or National Guard,

then signature of unit commander or designee is required.)

23B. DATE SIGNED (MM/DD/YYYY)

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, XXXXX