VA Form 21-8940 is the application for Total Disability based on Individual Unemployability (TDIU). The fictional example below fills 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 it is invented; put your own facts from your own records on the official form.
Start from VA's form page, which offers the PDF and an online version. The form collects facts. Whether those facts qualify you depends on the rating and employment rules in the TDIU eligibility guide.
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 | Mara's fictional entry | Check before you enter yours |
|---|---|---|
| 14. Date your disability affected full-time employment | 06/13/2022 | Attendance, treatment and changed-duty records. The first effect on work is often not the last day worked. |
| 15. Date you last worked full time | 09/29/2023 | The employer's schedule or your final full-time pay period. |
| 16. Date you became too disabled to work | 03/14/2025 | Her own account, explained in item 26. Explain a later part-time job instead of leaving it out. |
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
| Item | Mara's fictional entry | Check before you enter yours |
|---|---|---|
| 17A to 17C. Most you ever earned in one year, the year, your occupation that year | $52,400; 2021; emergency dispatcher | Search every year you worked, not only the last job. |
| 18. All employment, including self-employment, for the last five years you worked | (1) Lakeview County Emergency Communications (fictional), emergency dispatcher, 40 hours a week, 03/07/2016 to 09/29/2023, 31 days lost from illness, highest gross earnings $4,420 a month. (2) Harbor Supply Co. (fictional), inventory clerk, 16 hours a week, 10/16/2023 to 03/14/2025, 12 days lost from illness, highest gross earnings $1,180 a month. | This means the last five years you worked, not the last five calendar years. Include any military duty, including inactive duty for training, and any self-employment. |
| 19. If you are currently serving in the Reserve or National Guard, does a service-connected disability prevent you from performing your military duties? | Does not apply; Mara is not serving. | If you serve, answer it. VA may send Form 21-4192 to your unit commander. |
| 20A. Total earned income for the past 12 months | $9,440 (June 2024 to May 2025, added up from her pay stubs) | This is the 12 months before you sign, not your last tax year. |
| 20B. Current monthly earned income, if presently employed | Left blank; she is not working. | Fill it in if you work at all, including part time. |
| 21A. Did you leave your last job or self-employment because of your disability? | Yes, explained in item 26 | A "Yes" needs an explanation in item 26. Separate a disability-related change from a layoff or business closure. |
| 21B. Do you receive or expect to receive disability retirement benefits? | No | Answer "Yes" for any disability retirement you receive or expect. |
| 21C. Do you receive or expect to receive workers' compensation benefits? | No | Answer "Yes" if you receive workers' compensation or expect to. |
| 22. Have you tried to get work since you became too disabled to work? | No | If "Yes," list only real applications in 22A to 22C: employer, type of work and date applied. |
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.
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.
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.
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.
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.
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.
| Job or business and type of work | From and to; full or part time | Hours per week and highest gross earnings per month | Time lost from illness | Actual duties and changed duties | Why it ended; source of that account |
|---|---|---|---|---|---|
| [Employer or own business] | [Dates and schedule] | [Payroll, invoices, or an estimate flagged for checking] | [Dates or hours and source] | [Tasks; who took over what] | [Your recollection, an employer record, or both] |
| [Next role] | [Dates and schedule] | [Amount and record] | [Dates or hours] | [Tasks and help received] | [Reason and source] |
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 September 23, 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.
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.
Sources and scope
Checked September 23, 2026: all four pages of the July 2024 Form 21-8940, VA's form page, 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, her employers and every amount are fictional. Confirm the form edition on VA's form page when you file.
VA Form 21-526EZ Example: Filling Out the 2026 Form
VA Form 10182 Example: Choosing a Board Docket (2026 Form)
TDIU and a Protected Work Environment: Documenting the Facts