If your employer will not return VA Form 21-4192, VA should not deny your TDIU (Total Disability based on Individual Unemployability) claim for that reason alone. VA's claims manual tells staff to send the form to your employers, follow up once, and then tell you that getting the information is ultimately your responsibility, which you can meet with your own records and a signed statement. Do not fill in or sign the employer's sections yourself.

Form 21-4192 belongs to the employer. On the August 2024 edition, Sections II and IV are marked "To be completed by employer," and item 23A is the employer's or supervisor's signature under a certification that the answers are true. The form's Privacy Act notice tells employers that responding is voluntary, which is one reason some never answer. Your own form is the VA Form 21-8940 work history, and the broader rules are in the TDIU eligibility guide.

What VA does when it requests Form 21-4192

VA's claims manual, M21-1, Part VIII, Subpart iv, Chapter 3, Section B (employment topic dated July 29, 2021), sets these steps:

  1. When your Form 21-8940 arrives, VA sends Form 21-4192 to each employer you worked for during your last year of employment and sends you a copy. It does this even if you stopped working five or more years ago, and even if you may be working now.
  2. If no completed form comes back within 15 days, VA sends the employer a follow-up allowing another 15 days and notifies you that it is ultimately your responsibility to obtain the information.
  3. If the employer answers only with a website that lacks the requested information, VA asks again and allows 10 more days. If the employer says only that you retired, VA asks whether the retirement was because of disability and, if so, which disability.
  4. VA does not send the form to a business you report as closed, and it does not send it when you report self-employment. A federal employer's information is requested as federal records. If you currently serve in the Guard or Reserve, VA may send the form to your unit commander.
  5. VA should not hold up a grant the evidence already supports while it waits for the form, and the manual says not to deny a TDIU claim solely because an employer failed to return it.

Those steps do not make a missing form harmless. The facts the employer would have supplied still matter, and after the follow-up, VA expects you to help fill the gap.

Why not fill in the employer's part yourself

Some online guides suggest completing the employer's fields yourself and writing that the employer refused to sign. The form does not support that. The employer sections, the employer's certification and the penalty warning for knowingly false statements all assume the employer is the one answering. A form in your handwriting with those sections filled in also blurs whose account VA is reading. Put the same facts in your own signed statement, say they are your account, and attach the records behind each one.

Match each 21-4192 item to a record you can get

Form 21-4192 itemWhat the employer would reportRecords you may be able to supply
7 and 8. Beginning and ending datesWhen you started and stoppedOffer letter, first and last pay stubs, separation letter, a Social Security itemized earnings statement (Form SSA-7050)
9. Type of workJob title and dutiesJob description, job posting, performance reviews
10. Amount earned in the 12 months before your last day, before deductionsGross payW-2s, final year-to-date pay stub, payroll portal printouts
11. Time lost in those 12 months because of disabilityDays or hours missedLeave records, Family and Medical Leave Act approvals, timesheets, attendance warnings, doctors' work notes
12A and 12B. Hours worked daily and weeklyYour scheduleSchedules, timesheets, shift-change messages
13. Concessions made because of age or disabilityAccommodations and changed dutiesAccommodation requests and replies, modified-duty memos, a coworker's or supervisor's statement of what they saw
14A and 14B. Reason work ended and date last workedTermination reason and last daySeparation or termination letter, resignation letter, disability retirement paperwork
15A to 16B. Last payment and any lump sumFinal pay and lump sumsFinal pay stub, severance agreement
18 to 21C. Sick, retirement or other benefits from this jobBenefit type, amount and datesShort- or long-term disability approval letters, retirement award letters
17A and 17B. Guard or Reserve duty statusCurrent duty status and limitsVA sends this part to your unit commander, not a civilian employer.

An employer that will not complete the form may still confirm dates, title and pay in a short letter or through its employment verification service. Ask for the facts it can verify, and share VA's Form 21-4192 page, which offers a PDF and an online route for the employer. Do not send your medical file to a former employer to get a signature.

Make the missing response visible

Record who received the request, when, and what happened. A useful log is factual, short and written at the time:

Date and methodContact or departmentWhat you requestedResponse or delivery proofNext step
[Date; email, mail or phone][HR, payroll or supervisor][Form 21-4192 or specific employment facts][Reply, returned mail, delivery receipt or no response][One follow-up and its date]
[Follow-up][Person reached][Same request, clarified][Exact answer or no answer][Tell VA and identify other records]

Keep copies of each request and the employer's exact words. If the business closed, note how you learned that and any record that shows it. Write "did not respond" rather than "refused" when you only know the request went unanswered.

Fictional example: Theo emailed HR on April 3, followed up by mail on April 18, and received a May 2 reply saying the company only verifies dates and job title. He sends VA that reply, his W-2s and final pay stub, and a statement describing his changed schedule from his own experience. His statement is his account; it does not become an employer certification.

Tell VA what you can and cannot obtain

Send a short dated statement naming the employer, your contact attempts, the reply or lack of one, and the records you are attaching. Ask VA to consider them and to tell you if it needs anything else. VA's duty to assist covers reasonable efforts to get records you identify; it cannot force a private employer to fill out every item.

I requested VA Form 21-4192 from [employer and contact] on [date] by [method] and followed up on [date]. [State the actual reply, or that none has arrived as of a date.] I have attached [specific pay, schedule or separation records] for [period]. I can describe my duties and limitations from my own experience, but I cannot certify the employer's records or sign for the employer. Please tell me if you need another record or contact detail.

A coworker or supervisor who saw your changed duties can also write a statement about what they personally observed. Check your VA notice for its response date and upload instructions.

To turn your notes into a clear statement, Claim Raven's free Personal Statement Builder works without an account; it drafts your own account, not an employer certification. Claim Raven sells other claim tools and has a commercial interest in this topic.

If VA denies TDIU anyway, compare the stated reason with the evidence list before you choose a review. Matching the denial reason to the missing work evidence walks through that.

Sources and scope

Checked September 23, 2026: the August 2024 Form 21-4192 and VA's form page; the employer-request steps in M21-1, Part VIII, Subpart iv, Chapter 3, Section B, read on Claim Raven's reference page and in VA's KnowVA source; VA's duty-to-assist page; and the Social Security Administration's Form SSA-7050 page. Theo is fictional. The manual guides VA staff; follow the specific notice VA sends you.