Items 1 and 2 and Section I
The name and address of the Veteran's employer and a return address, then the Veteran or beneficiary's name, Social Security number, VA file number if applicable and date of birth in Items 3 to 6.
21-4192
Request for Employment Information in Connection with Claim for Disability Benefits
- Agency
- VA
- Revision
- August 2024
- Fillable fields
- 61
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-4192: Request for Employment Information for a Disability Claim
VA Form 21-4192 is the U.S. Department of Veterans Affairs Request for Employment Information in Connection with Claim for Disability Benefits. It is an employer's form. VA's form page says to use it if you're an employer and you need to send VA information about a Veteran who's applying for Individual Unemployability disability benefits, and that the Veteran's most recent employer completes and submits it.
The instructions are addressed to the employer: the Veteran named in Item 3 has filed a claim for disability benefits and has stated that he or she was recently employed by you. The form asks the employer to complete Sections II, III and IV, covering employment and earnings, Reserve or National Guard duty status and any sick, retirement or other benefits, then sign and date it.
The form is two pages. VA's page says it 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.
What's on VA Form 21-4192
Section II: employment information
Beginning and ending dates of employment, type of work, amount earned during the 12 months before the last date of employment before deductions, time lost due to disability and hours worked daily and weekly.
Section II: concessions and last payment
Any concessions made to the employee by reason of age or disability, the reason employment ended and date last worked, the date and gross amount of the last payment and whether a lump sum payment was made.
Section III: Reserve or National Guard duty status
The Veteran's current duty status and whether the Veteran has any disabilities that prevent them from performing their military duties.
Section IV: benefit entitlement and payments
Whether the Veteran receives or is entitled to sick, retirement or other benefits from this employment. If yes, the type of benefit, gross monthly amount, the date it began, the first payment date and the date it will stop, if known.
Remarks, certification and notices
Item 22 holds remarks. The certification says the statements are true and complete, followed by the penalty, Privacy Act and respondent burden notices, about 15 minutes.
How an employer completes VA Form 21-4192
- 1
Check the Veteran's identification
Section I names the Veteran or beneficiary the request is about. By hand, the form asks for ink, neat and legible printing, one letter per box and each applicable circle filled in.
- 2
Complete Section II
Enter the employment dates, type of work, earnings, time lost, hours, concessions, reason for termination and last payment details.
- 3
Complete Section III if it applies
Fill in the duty status questions only if the claimant is currently serving in the Reserve or National Guard.
- 4
Complete Section IV
Answer Item 18 about sick, retirement or other benefits. The form says a yes means completing Items 19 through 21C.
- 5
Sign, date and send it
The instructions ask the employer to sign and date Items 23A and 23B, then mail the form to the Evidence Intake Center or use the online version.
Why fill Form 21-4192 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
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- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and getting help
By mail
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Online
VA's form page says you can fill out VA Form 21-4192 online instead of filling out and sending the paper form.
Free help
The instructions say to call VA toll-free at 1-800-827-1000 for free help in completing the form. For TDD, the Federal number is 711.
Edition
The August 2024 edition supersedes the July 2021 edition. It carries OMB Control No. 2900-0065, which expires 08/31/2027.
Related forms
21-8940
Veteran’s Application for Increased Compensation Based on Unemployability
176 fields, 4 pages
21-4140
Employment Questionnaire
59 fields, 2 pages
21-526EZ
Application for Disability Compensation and Related Compensation Benefits
345 fields, 15 pages
21-4138
Statement in Support of Claim (VA Form 21-4138)
33 fields, 2 pages
Who completes VA Form 21-4192?
This form is filled in by an employer, not by the Veteran.
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Questions about Form 21-4192
Who fills out VA Form 21-4192?
VA's form page says the Veteran's most recent employer completes and submits it. The signature in Item 23A is the employer's or supervisor's.
What is VA Form 21-4192 used for?
VA's page says employers use it to send VA information about a Veteran who's applying for Individual Unemployability disability benefits.
Which sections does the employer complete?
The instructions ask the employer to complete Sections II, III and IV. Section III is only for a claimant currently serving in the Reserve or National Guard.
Which form does the Veteran file for Individual Unemployability?
VA's page lists VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, as the related form.
Can an employer submit VA Form 21-4192 online?
Yes. VA's form page says you can fill out VA Form 21-4192 online instead of filling out and sending the paper form.
Where is the form mailed?
The form says to mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.