VA Form 21-8940 Example: Two Filled-In TDIU Applications and a Checklist

VA Form 21-8940 is the application for Total Disability based on Individual Unemployability (TDIU), which pays at the 100% rate when service-connected disabilities keep you from holding a substantially gainful job. The current edition is dated July 2024. Get it from VA's Form 21-8940 page, which offers the PDF and an online version, then use the two filled-in fictional examples below to check your own entries.

The examples fill in the employment items of the current July 2024 edition one by one, so you can see how three different work dates, a part-time job and the income questions fit together. Every name, date and dollar amount in them is invented; put your own facts from your own records on the official form.

The form collects facts. Whether those facts qualify you depends on the rating and employment rules in the TDIU eligibility guide and in the next section.

Who the form is for: the 4.16(a) thresholds and 4.16(b)

VA's TDIU rule, 38 C.F.R. 4.16, has two paths.

The schedular path, 4.16(a). VA may assign a total rating when you are "unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities" and you have either:

• one service-connected disability rated 60% or more; or
• two or more service-connected disabilities, with at least one rated 40% or more and a combined rating of 70% or more.

For the 60% or 40% disability, the rule counts some groups as one: disabilities of one or both arms or legs, including the bilateral factor; disabilities from a common cause or a single accident; disabilities of a single body system, such as orthopedic or neuropsychiatric; multiple injuries incurred in action; and multiple disabilities incurred as a prisoner of war. The disability calculator combines your ratings, including the bilateral factor.

The extraschedular path, 4.16(b). If you do not meet the percentages but are unemployable because of service-connected disabilities, the rule tells rating boards to submit the case to the Director, Compensation Service, with "a full statement as to the veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors." Much of that statement comes from your 21-8940.

In the Board decision cited later on this page, the Board found the veteran did not meet 4.16(a), then granted TDIU under 4.16(b) itself, citing the October 2025 Court of Appeals for Veterans Claims decision in Witkowski v. Collins, which it read as allowing the Board to "adjudicate extraschedular TDIU in the first instance." For how TDIU claims tend to turn out, see Claim Raven's TDIU approval rate page.

Item 8: list only service-connected disabilities

Item 8 asks, "What service-connected disability(ies) prevent(s) you from securing or following any substantially gainful occupation?" List service-connected conditions only. Section 4.16(a) asks whether you are unemployable "as a result of service-connected disabilities" and says nonservice-connected disabilities "will be disregarded" when the percentages are met, and 38 C.F.R. 4.19 bars a total rating based on unemployability "associated with advancing age or intercurrent disability."

One refinement: VA's claims manual says a TDIU request can go with "an initial request for SC for the underlying disabilities claimed to cause unemployability," and that a claimant with several service-connected disabilities must name at least one that causes the unemployability (M21-1, Part VIII, Subpart iv, Chapter 3, Section B). So a condition you are claiming for service connection in the same filing can be listed. Explain what each condition does to your work in item 26.

Items 9 to 13 ask whether a doctor treated you or a hospital admitted you in the past 12 months, with dates, names and addresses. Put dates that do not fit in item 26.

The dates describe different events

Items 14, 15 and 16 ask three separate questions: when your disability first affected full-time work, when you last worked full time, and when you became too disabled to work. A truthful history can give three different answers.

Fictional example: Mara worked full time as an emergency dispatcher until September 2023. Her service-connected back condition began causing missed shifts in June 2022. She then worked part time as an inventory clerk until March 2025.

Item 15 is usually provable with a pay record. Item 16 is your account of when steady work became impossible, so after part-time work like Mara's it can fall later than item 15. VA's claims manual tells staff to check items 14 and 15 against the job table in item 18.

These dates can affect back pay. In Board decision A25091918 (October 23, 2025), the Board of Veterans' Appeals granted TDIU from May 20, 2024, which it described as "the date the Veteran requested in his VA Form 21-8940." VA had also received his intent to file and claim on that date.

Items 17 to 22: earnings, jobs and why work ended

Items 23 to 25 cover education and training before and after you became too disabled to work. Mara's fictional entries: high school plus one year of college; an emergency medical dispatcher certification in 2016; no training since. A course can matter even if it did not lead to a job.

Mara's fictional item 26 (Remarks) entry:

Item 16: After leaving my dispatcher job, I worked part time as an inventory clerk from 10/16/2023 to 03/14/2025. I stopped because I could not stay on my feet for a shift or lift stock boxes, and I missed 12 days in my last year there because of back flare-ups. Item 21A: I left my dispatcher job on 09/29/2023 after my supervisor told me my absences could not continue.

The five-year employment table in item 18

The form's wording is "List all your employment including self-employment for the last five years you worked (Include any military duty including inactive duty for training)." Each of its five blocks asks for the employer (or unit) name and address, type of work, hours per week, dates from and to, time lost from illness and highest gross earnings per month. More jobs go in Section V, Remarks. VA's claims manual says the minimum history it needs to contact employers is your last year of employment, and that if you list less than five years, VA assumes that is your whole work history unless other evidence conflicts (M21-1, Part VIII, Subpart iv, Chapter 3, Section B).

Marginal employment versus substantially gainful employment

You can have some earnings and still qualify. Section 4.16(a) says, "Marginal employment shall not be considered substantially gainful employment," and gives two tests:

• The income test. Marginal employment "generally shall be deemed to exist" when your earned annual income does not exceed the Census Bureau's poverty threshold for one person.
• The facts-found test. It may also exist "on a facts found basis" when you earn more, including "employment in a protected environment such as a family business or sheltered workshop."

VA must also consider "the nature of the employment and the reason for termination." On the form, items 18, 20A, 20B and 21A carry the facts, and item 26 carries the context: who made allowances for you, what you could no longer do, and why the work ended.

A second fictional example: part-time work in a family business

Ray Ortiz (fictional) has service-connected PTSD rated 70%, which alone meets the 60% threshold, and diabetes that is not service connected. He left full-time work as a fleet mechanic in 2022 and now works a few hours a week at his brother's auto repair shop, where he works alone and can leave when panic symptoms start.

Ray's fictional item 26 (Remarks) entry:

Items 16 and 18: Since 09/2022 I have worked about 12 hours a week at my brother's shop. He lets me work alone, pick my hours and leave without notice when I have panic attacks, which happens most weeks. Item 21A: I left Tri-County Fleet Services on 07/15/2022 after repeated absences and two incidents with customers.

When VA sends Form 21-4192 to the shop, its item 13 asks for "concessions (if any) made to employee by reason of age or disability," which is where his brother can confirm those allowances.

What you certify when you sign

Section VI is more than a signature line. By signing, you:

• authorize employers, service providers and government agencies to give VA information about you, except protected health information;
• certify that, because of your service-connected disabilities, you cannot secure or follow any substantially gainful occupation, and that your answers are true and complete;
• acknowledge that if VA grants TDIU, you must tell VA immediately if you return to work, and that TDIU paid after you start working may be treated as an overpayment you have to repay.

You sign in item 27 and date it in item 28. The form also warns of fines or imprisonment for knowingly false statements. If you take any job after a TDIU grant, including part-time or self-employed work, report it right away and keep proof that you did. VA may also ask you to verify your employment status; VA's TDIU page says that request uses Form 21-4140, the Employment Questionnaire.

A worksheet that catches gaps before the form does

Copy one row per job or self-employment period. Keep the underlying records separate and private. "Unknown" is better than a made-up date; note the record you will check.

Then write a four-line date check: first effect on full-time work; last full-time day; date you say steady work became impossible; last day of any work. If those dates differ, explain why in item 26.

If you cannot rebuild your list of employers, Social Security can help. The free online Statement shows yearly earnings totals but no employer names. An itemized earnings statement, requested with Form SSA-7050, lists employers; on November 8, 2026, the Social Security Administration's form page listed $61 for a non-certified itemized statement.

For a part-time job like Mara's, keep the pay records that show each year's earned income. How VA compares earned income with the Census poverty threshold explains why that yearly figure matters.

If you were self-employed, VA's claims manual tells staff to ask you for a statement of the work you did, your weekly hours and the time you lost in the past 12 months, instead of sending an employer form (M21-1, Part VIII, Subpart iv, Chapter 3, Section B).

Employer forms and next steps

VA sends Form 21-4192 to the employers you worked for in your last year of work. It is the employer's form, not a page for you to complete. If an employer does not answer, see what to document when an employer will not return Form 21-4192.

How Form 21-4192 works alongside the 21-8940

On the current August 2024 Form 21-4192, the employer reports your employment dates, type of work, earnings and time lost to disability in the 12 months before your last day, hours, any concessions made for age or disability, why the job ended and any benefits, then signs in items 23A and 23B. Section III is only for a current Reserve or National Guard member.

VA's claims manual (M21-1, Part VIII, Subpart iv, Chapter 3, Section B) says VA requests the form for your last year of employment when your 21-8940 arrives, sends you a copy, and follows up after 15 days, telling you it is ultimately your responsibility to get the information. VA does not deny TDIU only because an employer failed to return it, and does not send it to a closed business or for self-employment. VA's Individual Unemployability page lists it as one of two forms you submit, so you can also ask your last employer to complete it and send it with your application. The 21-4192 example shows a completed one.

Check every date and amount against pay, tax and training records before you sign, and keep a copy of what you submit with its confirmation. An accredited Veterans Service Organization representative can review the form with you at no charge; you can also find a VSO near you.

VA Form 21-8940 questions

Sources and scope

Checked November 8, 2026: all four pages of the July 2024 Form 21-8940, VA's form page (form revision date July 2024), the August 2024 Form 21-4192, VA's Individual Unemployability page, 38 C.F.R. 4.16 and 4.19 (eCFR, up to date as of November 5, 2026), VA's TDIU development steps in M21-1, Part VIII, Subpart iv, Chapter 3, Section B, the SSA-7050 form page and Board decision A25091918. Mara, Ray, their employers and every amount are fictional. Confirm the form edition on VA's form page when you file.