21-4192

Request for Employment Information in Connection with Claim for Disability Benefits

Agency
VA
Revision
2024-08-28
Fillable fields
61
Fill 21-4192 online
21-4192

Form 21-4192: Request for Employment Information in Connection with Claim for Disability Benefits

Use VA Form 21-4192 if you’re an employer and you need to send us information about a Veteran who’s applying for Individual Unemployability disability benefits. The Veteran’s most recent employer must complete and submit this form.

How to fill out Form 21-4192 online

  1. 1

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  2. 2

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  3. 3

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