VA Form 21-4192 asks an employer to describe a veteran's work, earnings, disability-related absences, and reason for leaving. It supports a claim for Total Disability based on Individual Unemployability, usually called TDIU. The employer completes and signs the employment information. The veteran's application is Form 21-8940.

I checked the August 2024 edition on September 25, 2026. It replaces July 2021 and has two pages, four sections, and numbered items ending at 23B. Download it from VA's Form 21-4192 page, which also links an online employer form.

Who completes it, and why VA asks

VA's form page describes 21-4192 as the form for the veteran's most recent employer. The PDF addresses the employer directly and asks for Sections II, III, and IV, with the applicable military-duty section completed only when relevant.

An employer can report facts from payroll, attendance, personnel records, and direct knowledge. The form does not ask the employer to assign a VA rating or make the final TDIU decision.

The veteran should keep the employment history on 21-8940 accurate and help identify the right employer contact. That does not authorize the veteran to sign the employer's certification. If a human-resources office needs clarification, provide the request and the official form, rather than a suggested medical conclusion.

The 21-8940 example explains the veteran's side. TDIU eligibility depends on the applicable disability and employment rules, not simply whether one employer checks a box.

Items 1 and 2: Employer and return address

Item 1 identifies the veteran's employer and address. Item 2 is the return-to address block. If VA has supplied a request with those details, preserve them and follow the return instructions.

For an employer with several locations, the relevant contact may be a centralized payroll or human-resources office rather than the building where the veteran worked. A practical first step is to confirm which office can access the old records and who is authorized to sign.

That contact check is preparation, not a separate VA eligibility requirement. Its purpose is to avoid sending the form to someone who cannot answer it.

Section I: Identify the veteran, Items 3 to 6

  • 3: Veteran or beneficiary's name.
  • 4: Social Security number.
  • 5: VA file number, if applicable.
  • 6: Date of birth.

Check these against the request before disclosing employment information. The same employer may have multiple former employees with similar names. Send the completed form through the official route rather than exposing identifiers in an ordinary group email.

Section II: Employment dates and earnings, Items 7 to 12

7 and 8 ask for the beginning and ending dates of employment. 9 asks for the type of work performed. Use an understandable description of the work, not only an internal position code.

10 asks for earnings during the 12 months preceding the last date of employment, before deductions. This is not automatically the last tax year's W-2 total. Use the requested period and gross pay.

11 asks for time lost because of disability during that same 12-month period. Separate disability-related time from unrelated vacation or other absences. If available records do not establish why particular time was missed, explain the limit rather than assigning a cause.

12A and 12B ask for hours worked daily and weekly. If the schedule changed, use Item 22 to explain the periods. A single weekly figure can otherwise hide a reduction from full-time to part-time work.

The official PDF asks for these facts separately because pay, hours, and attendance describe different parts of the employment history. Low earnings alone do not explain why the person stopped working.

Concessions and separation, Items 13 and 14

13 asks what concessions the employer made because of age or disability. Describe actual changes, such as reduced duties, a changed schedule, additional breaks, or help from another worker, only when the employer can support them.

A useful answer names the task and the change. For instance, an employer could explain that another worker took over lifting duties beginning on a particular date. That is more specific than an unexplained label such as light duty.

14A asks why employment ended if the veteran is no longer working. It specifically asks the employer to identify disability retirement when applicable. A business closure, ordinary retirement, resignation, and disability retirement are different answers.

14B asks for the date last worked. That can differ from Item 8's employment-ending date if the employee remained on the rolls after the final shift. Explain the difference rather than forcing both dates to match.

Final payments, Items 15 and 16

15A asks for the last payment date, and 15B asks for that payment's gross amount.

16A asks whether a lump-sum payment was made. If yes, 16B asks for its date and gross amount. Use the records to distinguish a final paycheck from a separate payout. The payment date can be later than the last day worked without either date being wrong.

If the payment includes several components, Item 22 gives the employer room to explain them. Do not silently turn a payout for accrued leave into wages for days the veteran actually worked.

Section III: Reserve or National Guard status, Item 17

Complete this section only if the claimant currently serves in the Reserve or National Guard. 17A asks for current duty status. 17B asks whether disabilities prevent performance of military duties.

A civilian employer completing its own records should not guess at a military-duty answer it cannot verify. Follow the request relevant to the employer or unit receiving the form. If the section does not apply, it should not become a fictional account of military service.

Section IV: Benefits, remarks, and signature, Items 18 to 23

18 asks whether the veteran receives or is entitled to sick, retirement, or other benefits because of employment with that employer. A yes requires 19 through 21C:

  • 19: Type of benefit.
  • 20: Gross monthly amount.
  • 21A: Date the benefit began.
  • 21B: Date the first payment was issued.
  • 21C: Date the benefit will stop, if known.

The beginning of entitlement and the first payment date need not be identical. Use the plan's records and explain unresolved details.

22, Remarks, is for relevant explanations. Good uses include changed hours, different last-worked and termination dates, or the source and limits of older records. Label the item being explained so VA does not have to infer the connection.

23A requires the employer or supervisor's signature, and 23B the signing date. The signer certifies that the answers are true and complete to the best of their knowledge and belief. The veteran should not sign this line for an unresponsive former employer.

Fictional example: Last shift and final paycheck differ

This is an invented payroll exercise. There is no real veteran or employer, and the numbers are not evidence of TDIU eligibility.

Assume an employer's records show a warehouse employee worked from April 5, 2021, through February 28, 2026. The employee's final shift was February 20, followed by approved leave. The final paycheck arrived March 6.

  • 7: 04/05/2021.
  • 8: 02/28/2026.
  • 9: Warehouse order picking and packing.
  • 10: $38,400 gross during the specified final 12 months, as calculated for this example.
  • 11: 96 hours of documented disability-related absence in that period.
  • 12A and 12B: Eight hours daily and 40 weekly before the explained schedule change.
  • 13: Reduced lifting duties beginning 11/03/2025, with the actual reassigned tasks described in a real response.
  • 14A: The employer's documented reason for separation, without inventing a medical opinion.
  • 14B: 02/20/2026.
  • 15A and 15B: 03/06/2026 and $1,200 gross.
  • 16A: No, assuming no separate lump-sum payment.
  • 22: Explanation of the leave period and any schedule change.
  • 23A and 23B: Employer or supervisor signature and actual signing date.

The three February and March dates refer to different events. Copying one into all three fields would remove useful information.

Where to submit it

Online: The employer can use the online tool linked from VA's 21-4192 page. This is the employer-information submission, not the veteran's 21-8940 application.

Mail: The PDF lists Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. Follow any specific return instructions on VA's request.

Fax: The PDF does not identify a form-specific fax. VA publishes 844-531-7818 for compensation intake and 248-524-4260 for applicants outside the United States on its applying-for-benefits page. These are general compensation routes. Confirm with VA at 800-827-1000 if the employer's request does not specify where to fax it.

Keep a copy and a submission receipt. Do not send the form to the paperwork-comments email printed in the privacy notice; that address is not the claims submission route.

Common problems and the next step

The main checks are concrete: the correct earnings period, gross rather than take-home pay, time lost specifically because of disability, accurate payment dates, and the employer's signature. An unexplained mismatch with 21-8940 should be addressed through records and clarification, not by changing one form to copy the other.

After submission, VA considers the employer's information with the rest of the TDIU evidence. A returned form does not itself grant TDIU. If the business closed or will not respond, tell VA what happened and preserve your attempts to obtain the records. See what to document when an employer will not complete 21-4192.

You can prepare your own account of the work problems separately. Raven Scribe helps turn your facts into an editable work-impact statement. Its free personal-statement builder is available without an account; the broader document writer has account and plan limits. Your statement explains your experience and does not replace the employer's certification.

Sources and scope

Verified September 25, 2026: the August 2024 21-4192 PDF, VA's official form page and linked employer tool, and VA's general compensation submission instructions. The example is fictional. This article explains the form, not whether a particular job was substantially gainful or whether TDIU should be granted.

Where to go next

Disclaimer

I'm Landon, founder of Claim Raven and a U.S. Army veteran, not a lawyer, VSO, or VA-accredited representative. Claim Raven is data analysis, not legal, medical, or VA-accredited advice. Use the employer's actual records and the current VA request. An accredited representative can help with disputed employment evidence.