VA Form 21-4192: Request for Employment Information in Connection with Claim for Disability Benefits

What VA Form 21-4192 is for

Form 21-4192 asks an employer to describe your work, earnings, time lost because of disability and why the job ended. It supports a claim for Total Disability based on Individual Unemployability (TDIU). VA sends it to your employers itself; use this if you want to hand an employer a copy with your name and their address already filled in.

This is the employer's form. Your own TDIU application, with your work history, is Form 21-8940. Fill in Form 21-8940.

Parts someone else completes

The employer completes Sections II and IV (items 7 to 16 and 18 to 22) from its payroll, attendance and personnel records, and an employer official or supervisor signs and dates items 23A and 23B. Section III (item 17) is completed only if you serve in the Reserve or National Guard now, and VA may send that part to your unit commander. Do not fill in or sign the employer's sections yourself.

What you fill in by hand

The filler never asks for your Social Security number, VA file number, date of birth or signature. You write those in by hand. Leave these boxes for yourself:

• Item 4: Social Security number (and the SSN line at the top of page 2)
• Item 5: VA file number
• Item 6: date of birth
• Items 7 to 22
• Items 23A and 23B: signature and date

Where to send it

• Give the form to the employer's human resources or payroll office. VA's Form 21-4192 page also links an online form the employer can use instead.
• The employer mails the finished form to the address printed on it: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. If VA's request gives other return instructions, follow them.
• Do not send your medical file to a former employer to get a signature.
• If the employer does not answer, tell VA what you tried, keep a dated log of each request, and send your own records, such as pay stubs, W-2s and leave records, with a signed statement.
• Keep a copy of what you give the employer.

Claim Raven does not submit forms to VA. You review the filled PDF, sign and date it, and send it to VA yourself. Claim Raven is independent and is not affiliated with VA.

Official form and guide

• VA's page for Form 21-4192 on VA.gov
• VA Form 21-4192 example and how to fill it out

This filler uses the August 2024 edition of the form.