21-4192 Request for Employment Information in Connection with Cl

OMB Control No. 2900-0065
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR
DISABILITY BENEFITS
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 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.
Where to Send Correspondence - After completing the form, mail to:
Department of Veterans Affairs
Evidence Intake Center
P.O. Box 4444
Janesville, WI 53547-4444
SECTION I - 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 in each applicable circle to help expedite processing of the form.
3. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)

4. SOCIAL SECURITY NUMBER

6. DATE OF BIRTH

5. VA FILE NUMBER (If applicable)

Month

Day

Year

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

Day

8. ENDING DATE OF EMPLOYMENT

Year

Month

Day

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

,

$

.

12A. NUMBER OF HOURS WORKED (Daily)

9. TYPE OF WORK PERFORMED
Year

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

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)

15B. GROSS AMOUNT
OF LAST PAYMENT

15A. DATE OF LAST PAYMENT
Month

Day

16A. WAS LUMP SUM
PAYMENT MADE?
YES

Year

NO

GROSS AMOUNT PAID

$

14B. DATE LAST WORKED
Month

Day

Year

Day

Year

16B. DATE PAID
Month

$

SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS
(Only complete if claimant is currently serving in the Reserve or National Guard)
17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?

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

NO

21-4192

SUPERSEDES VA FORM 21-4192, SEP 2017.

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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
Month

Day

21C. DATE BENEFIT WILL STOP (If known)

21B. DATE FIRST PAYMENT ISSUED
Year

Month

Day

Year

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 (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 Veteran Readiness 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: 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 2900-0065, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 15 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. 2900-0065 in any correspondence. Do not send your completed VA Form 21-4192 to this email address.
VA FORM 21-4192, XXX XXXX

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