How To Complete VA Form 21-4192

VA Form 21-4192: Request for Employment Information In Connection With Claim For Disability Benefits

Whenever a veteran decides to apply for a Total Disability Rating Based on Individual Unemployability (TDIU), they will need to complete a VA Form 21-8940. In addition to that form, the VA will also request that the veteran have his or her most recent employer complete a VA Form 21-4192. The purpose of this form is for the VA to gather information about the veteran’s most recent employment.

The process for completing this form is different from many of the other forms veterans will need to complete throughout their claim’s adjudication. First, the VA takes on most of the responsibility in sending out this form. Additionally, the form requires little information from veterans, and that information is only provided by the veteran themselves when he or she sends the form to their employer directly (see step 1a below). The VA’s process for acquiring these forms is as follows:

  1. The VA will send a VA Form 21-4192 to all the former employers which the veteran worked for during his or her last year of employment, as listed on the veteran’s VA Form 21-8940. At the same time, the VA will also send a copy of VA Form 21-4192 to the veteran and request that his or her previous employer complete and return the form.
    1. For the latter part of this step, the veteran needs to provide some information on the form. He or she will fill in the name and address of his or her former employer in box 1, followed by the VA’s Evidence Intake Center (EIC) address in box 2. The veteran will then fill out their identification information in Section I of the form, including their name (or the beneficiary’s name), Social Security Number, VA file number (if applicable), and date of birth. This is where the veteran’s role in completing this form ends.
  2. If the VA receives the VA Form 21-4192 from the Veteran’s former employer within 15 days, the VA will refer the claim to rating. If the form was not received, the VA will proceed to step three.
  3. The VA will send a follow-up request to the employer for VA Form 21-4192, allowing an additional 15 days for response. The VA will also notify the veteran that it is ultimately the veteran’s responsibility to obtain this information.

Since the veteran relies on his or her employer to fill out most of the form, it is best to send the form out as soon as possible after receiving one from the VA. In the event that the veteran’s former employer is no longer in business or for some other reason cannot provide the information outlined on the form, the veteran should inform the VA of this as soon as he or she receives the VA Form 21-4192 in the mail.

What Type Of Information Is The VA Requesting From The Veteran’s Former Employer?

On VA Form 21-4192, the employer will need to provide the following:

  • The veteran’s dates of employment
  • The type of work he or she performed
  • How much his or her earnings were
  • The amount of time lost due to disability
  • Hours worked daily and weekly
  • Any concessions made for the veteran on account of age or disability
  • Reason for termination
  • Date last worked
  • Date of last payment, including payment amount and date paid
  • If the veteran receives sick, retirement, or other benefits from the employer, including the type of benefit and gross monthly amount of benefit, and the dates the veteran has been and will continue to receive the benefit

The VA is not allowed to deny a TDIU claim solely because an employer failed to return a completed VA Form 21-4192.

Get Help With Your TDIU Claim

If you are looking for assistance filing or appealing your claim for TDIU, our experienced veterans disability attorneys are ready to help. Please contact us today at 800-448-5423 or via our free claim evaluation form. We can help you get the compensation you deserve.