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

OMB Approved No. 2900-0404
Respondent Burden: 45 minutes
Expiration Date: XX/XX/20XX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

VETERAN'S APPLICATION FOR INCREASED
COMPENSATION BASED ON UNEMPLOYABILITY
IMPORTANT: 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 mailing information on page 4
of this form.
SOCIAL SECURITY BENEFITS: Individuals who have a disability and meet medical criteria may qualify for Social
Security or 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 at https://secure.ssa.gov/ICON/main.jsp 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 may complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly, insert one letter per box,
and completely fill each applicable checkbox to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

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

5. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

6. EMAIL ADDRESS (If applicable)

ZIP Code/Postal Code
I agree to receive electronic correspondence
from VA in regards to my claim.

7. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

SECTION II - DISABILITY AND MEDICAL TREATMENT
8. WHAT SERVICE-CONNECTED DISABILITY(IES)
PREVENT(S) YOU FROM SECURING OR FOLLOWING
ANY SUBSTANTIALLY GAINFUL OCCUPATION?

9. HAVE YOU BEEN UNDER A DOCTOR'S
CARE AND/OR HOSPITALIZED WITHIN
THE PAST 12 MONTHS?
YES

NO

10. DATE(S) OF TREATMENT BY DOCTOR(S)
(Go to Item 26, Remarks to enter additional dates)
FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

11. NAME AND ADDRESS OF DOCTOR(S)

12. NAME AND ADDRESS OF HOSPITAL

13. DATE(S) OF HOSPITALIZATION
(Go to Item 26, Remarks to enter additional dates)
FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

SECTION III - EMPLOYMENT STATEMENT
14. DATE YOUR DISABILITY AFFECTED FULL-TIME
EMPLOYMENT (MM/DD/YYYY)

15. DATE YOU LAST WORKED FULL-TIME
(MM/DD/YYYY)

17A. WHAT IS THE MOST YOU EVER EARNED IN ONE YEAR?

$

VA FORM
XXX XXXX

17B. WHAT YEAR?

16. DATE YOU BECAME TOO DISABLED TO WORK
(MM/DD/YYYY)

17C. OCCUPATION DURING THAT YEAR?

,

21-8940

SUPERSEDES VA FORM 21-8940, JUN 2021.

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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) (Note: For additional employment information use Section V, Remarks)
NAME AND ADDRESS OF EMPLOYER (OR UNIT)

DATES OF EMPLOYMENT
FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST
FROM ILLNESS

HIGHEST GROSS EARNINGS
PER MONTH

$
NAME AND ADDRESS OF EMPLOYER (OR UNIT)

DATES OF EMPLOYMENT
FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

DATES OF EMPLOYMENT
FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST
FROM ILLNESS

DATES OF EMPLOYMENT
FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

DATES OF EMPLOYMENT
FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST
FROM ILLNESS

HOURS
PER WEEK

HIGHEST GROSS EARNINGS
PER MONTH

,
HOURS
PER WEEK

TYPE OF WORK

TIME LOST
FROM ILLNESS

HIGHEST GROSS EARNINGS
PER MONTH

,
HOURS
PER WEEK

TYPE OF WORK

TIME LOST
FROM ILLNESS

HIGHEST GROSS EARNINGS
PER MONTH

$

VA FORM 21-8940, XXX XXXX

,

TYPE OF WORK

$
NAME AND ADDRESS OF EMPLOYER (OR UNIT)

HOURS
PER WEEK

HIGHEST GROSS EARNINGS
PER MONTH

$
NAME AND ADDRESS OF EMPLOYER (OR UNIT)

,

TYPE OF WORK

$
NAME AND ADDRESS OF EMPLOYER (OR UNIT)

HOURS
PER WEEK

TYPE OF WORK

,

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VETERAN'S SOCIAL SECURITY NO.

SECTION III - EMPLOYMENT STATEMENT (Continued)
19. 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

20A. INDICATE YOUR TOTAL EARNED INCOME FOR THE PAST 12
MONTHS

$

20B. IF PRESENTLY EMPLOYED, INDICATE YOUR CURRENT MONTHLY EARNED
INCOME

,

$

21A. DID YOU LEAVE YOUR LAST JOB/SELF-EMPLOYMENT
BECAUSE OF YOUR DISABILITY?

21B. DO YOU RECEIVE/EXPECT TO RECEIVE
DISABILITY RETIREMENT BENEFITS?

NO (If "Yes," explain in Item 26, "Remarks")

YES

,

YES

NO

21C. DO YOU RECEIVE/EXPECT TO RECEIVE
WORKERS COMPENSATION BENEFITS?
YES

NO

22. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?
YES

NO

(If "Yes," complete Items 22A, 22B, and 22C)
22A.

22B.

22C.

NAME AND ADDRESS OF EMPLOYER

TYPE OF WORK

DATE APPLIED (MM/DD/YYYY)

NAME AND ADDRESS OF EMPLOYER

TYPE OF WORK

DATE APPLIED (MM/DD/YYYY)

NAME AND ADDRESS OF EMPLOYER

TYPE OF WORK

DATE APPLIED (MM/DD/YYYY)

SECTION IV - SCHOOLING AND OTHER TRAINING
23. EDUCATION (Check highest year completed)
GRADE SCHOOL

1

2

HIGH SCHOOL

9

10

3

4
11

5
12

6
COLLEGE

7

8
Fresh

Soph

Jr

Sr

24A. DID YOU HAVE ANY OTHER EDUCATION AND TRAINING BEFORE YOU WERE TOO DISABLED TO WORK?
YES

NO

(If "Yes," complete Items 24B and 24C)

24B. TYPE OF EDUCATION OR TRAINING

24C. DATES OF TRAINING
BEGINNING (MM/DD/YYYY)

COMPLETION (MM/DD/YYYY)

25A. HAVE YOU HAD ANY EDUCATION AND TRAINING SINCE YOU BECAME TOO DISABLED TO WORK?
YES

NO

(If "Yes," complete Items 25B and 25C)

25B. TYPE OF EDUCATION OR TRAINING

VA FORM 21-8940, XXX XXXX

25C. DATES OF TRAINING
BEGINNING (MM/DD/YYYY)

COMPLETION (MM/DD/YYYY)

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VETERAN'S SOCIAL SECURITY NO.

SECTION V - REMARKS
NOTE: This section can be used for any additional information, if needed.
26. REMARKS

SECTION VI - 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.
27. SIGNATURE OF CLAIMANT (Required)

28. DATE SIGNED (MM/DD/YYYY)

WITNESSES NEEDED IF "X" MARK IS MADE (Signature made by mark must be witnessed by two persons to whom the person making the statement is
personally known and the signature and address of such witnesses must be shown in Items 29A & 29B and 30A & 30B.
29A. SIGNATURE OF WITNESS (Sign in ink)

29B. ADDRESS OF WITNESS

30A. SIGNATURE OF WITNESS (Sign in ink)

30B. ADDRESS OF WITNESS

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.

SECTION VII - WHERE TO SEND CORRESPONDENCE
MAIL TO:
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
PRIVACY ACT INFORMATION: 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 Veteran Readiness and Employment Records - VA, published
in the Federal Register. Your response 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: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control
Number. The OMB control number for this project is 2900-0404, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 45
minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden to VA
Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0404 in any correspondence. Do not send your completed VA Form 21-8940
to this email address.
VA FORM 21-8940, XXX XXXX
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