Form VA Form 21-4140 VA Form 21-4140 Employment Questionnaire

OMB Approved No. 2900-0079
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

EMPLOYMENT QUESTIONNAIRE

IMPORTANT: You are receiving compensation at the 100 percent rate based on being unable to secure or follow a
substantially gainful occupation as a result of your service-connected disabilities. Section I needs to be completed in
order to identify the person filling out the form. If you were self-employed or employed by others, including the
Department of Veterans Affairs, at any time during the past 12 months, complete Section II of this form. If you have not
been employed during the past 12 months, complete Section III of this form. After completing the form, mail to:
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
DATE MAILED (MM/DD/YYYY)

STATION
ADDRESS
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information required in ink, neatly, and legibly to help process the form.

1. NAME OF VETERAN (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

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

3. VA FILE NUMBER

5. VETERAN'S SERVICE NUMBER (If applicable)

6. E-MAIL ADDRESS (Optional)

7. PRIMARY TELEPHONE NUMBER (Include Area Code)

8. ALTERNATE TELEPHONE NUMBER (Include Area Code)

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

City
Country

ZIP Code/Postal Code

10. WERE YOU EMPLOYED BY VA, OTHERS OR SELF EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS? (If "Yes,"
complete Section II only, if "No," complete Section III only)
YES
NO

SECTION II - EMPLOYMENT CERTIFICATION
List all employment for the past 12 months
11A. NAME AND ADDRESS OF EMPLOYER

(If self-employed, write "self")

11B. TYPE
OF WORK

11C. HOURS
PER WEEK

11D. DATES OF EMPLOYMENT
OR SELF-EMPLOYMENT

(MM/DD/YYYY)

FROM

VA FORM
XXX XXXX

21-4140

SUPERSEDES VA FORM 21-4140, JUL 2021.

TO

11E. TIME
LOST
FROM
ILLNESS

11F.
HIGHEST
GROSS
EARNINGS
PER MONTH

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VETERAN'S SOCIAL SECURITY NO.

SECTION II - EMPLOYMENT CERTIFICATION (Continued)
11A. NAME AND ADDRESS OF EMPLOYER

(If self-employed, write "self")

11B. TYPE
OF WORK

11C. HOURS
PER WEEK

11D. DATES OF EMPLOYMENT
OR SELF-EMPLOYMENT

(MM/DD/YYYY)

FROM

TO

11E. TIME
LOST
FROM
ILLNESS

11F.
HIGHEST
GROSS
EARNINGS
PER MONTH

I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief.
I UNDERSTAND THAT my continued entitlement to VA unemployability compensation benefits will be based on information that I have
furnished on this form or that I hereafter may be required to furnish VA.
12A. SIGNATURE OF VETERAN (REQUIRED)
12B. DATE SIGNED (MM/DD/YYYY)

SECTION III - UNEMPLOYMENT CERTIFICATION
Complete this section if you did NOT work during the past 12 months
I CERTIFY THAT I have not been employed by VA, others or self-employed during the past twelve months.
I FURTHER CERTIFY THAT the items completed on this form are true and correct to the best of my knowledge and belief. I believe that my
service-connected disability(ies) has not improved and continues to prevent me from securing or following gainful employment.
13A. SIGNATURE OF VETERAN (REQUIRED)
13B. 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 material 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 required to obtain or retain
benefits. 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 2900-0079, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 5 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. 2900-0079 in any correspondence. Do not send your completed VA Form 21-4140 to this email address.

VA FORM 21-4140, XXX XXXX

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