21-4140
Employment Questionnaire
VA Form 21-4140 is the U.S. Department of Veterans Affairs Employment Questionnaire. VA's form page says to use it if VA asked you to verify your employment status because you currently receive Individual Unemployability disability benefits for a service-connected condition.
The form opens with a note that the person receiving it gets compensation at the 100 percent rate based on being unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Section I identifies the Veteran. Item 10 asks whether the Veteran was employed by VA, others or self employed at any time during the past 12 months. A yes leads to Section II, a list of that employment, and a no leads to Section III, an unemployment certification.
The form is two pages. VA's page says the form can also be filled out online instead of sending the paper form. You can fill out the PDF free in your browser on this page and download the result without an account.
Items 1 to 9 ask for the Veteran's name, Social Security number, VA file number, date of birth, service number if applicable, an optional email address, primary and alternate phone numbers and current mailing address.
A yes or no question about employment by VA, others or self-employment during the past 12 months. The form says yes means Section II only and no means Section III only.
Items 11A to 11F list all employment for the past 12 months: employer name and address (write "self" if self-employed), type of work, hours per week, dates of employment, time lost from illness and highest gross earnings per month. The table continues on page 2.
A certification that the statements are true and complete, and that continued entitlement to VA unemployability compensation benefits will be based on the information furnished. The signature in Item 12A is marked required.
A certification of no employment by VA, others or self-employment during the past twelve months, with the statement that the service-connected disability has not improved and continues to prevent gainful employment. Item 13A is the required signature.
Page 2 states the penalty for willfully submitting a false statement, the Privacy Act notice and a respondent burden of about 5 minutes.
Enter the identification and contact details. The form says it can be completed online or by hand, and by hand it asks for ink, neat and legible printing.
Check yes or no for employment by VA, others or self-employment during the past 12 months.
With a yes, list all employment for the past 12 months in Section II. With a no, go to the Section III unemployment certification.
Sign Item 12A for Section II or Item 13A for Section III, both marked required, and enter the date signed.
Mail the form to the Evidence Intake Center in Janesville, Wisconsin, or use the online version linked from VA's form page.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
VA's form page says you can fill out this form online instead of filling out and sending the paper form.
The August 2024 edition supersedes the July 2021 edition. It carries OMB Approved No. 2900-0079, which expires 08/31/2027.
21-8940
176 fields, 4 pages
21-4192
61 fields, 2 pages
21-526EZ
345 fields, 15 pages
21-4138
33 fields, 2 pages
VA's form page and the form itself describe who completes it.
No tool matches that search.
VA's form page says to use it if VA asked you to verify your employment status because you currently receive Individual Unemployability disability benefits for a service-connected condition.
Everyone completes Section I and Item 10. The form says a yes to Item 10 means Section II only, and a no means Section III only.
Yes. Item 10 asks about employment by VA, others or self-employment, and Section II says to write "self" as the employer if self-employed.
Yes. VA's form page says you can fill out this form online instead of filling out and sending the paper form.
The form says to mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
The form estimates a respondent burden of 5 minutes.
