VA Form 21-4140 — Employment Questionnaire

What is VA Form 21-4140?

VA Form 21-4140 is the Employment Questionnaire from the U.S. Department of Veterans Affairs (VA). The form explains that you receive compensation at the 100 percent rate because your service-connected disabilities keep you from securing or following a substantially gainful occupation, often called individual unemployability or TDIU, and VA uses this form to check your employment status.

Section I identifies you. If you worked for VA, for others or for yourself at any time in the past 12 months, Section II lists each job with the employer, type of work, hours, dates, time lost from illness and highest gross monthly earnings, and you sign the employment certification. If you didn't work, you sign Section III, the unemployment certification, instead.

FileIt asks the questions in plain English and prints your answers on VA's own PDF, with your name and address in the form's letter-per-box rows and your Social Security number repeated at the top of page 2. The employment rows only appear if you worked, and the date signed lands beside the certification that applies. The finished questionnaire is saved to your vault.

Who needs to fill out VA Form 21-4140?

• Veterans receiving compensation at the 100 percent rate based on individual unemployability (TDIU) who have been asked by VA to verify their employment status.
• Veterans who worked for VA, for an employer or for themselves at any time in the past 12 months, and those who didn't work at all: both answer, in different sections.

When to use VA Form 21-4140

• When VA sends you the questionnaire or asks you to verify your employment.
• To report every job or self-employment in the 12 months before you complete the form.

What you need before you start

• Your Social Security number, VA file number, date of birth and service number (if applicable).
• Your current mailing address, phone numbers and email.
• For each job in the past 12 months: the employer's name and address (write "self" if self-employed), the type of work, hours per week, start and end dates, time lost from illness, and your highest gross earnings in a month.

What’s on VA Form 21-4140

The 2024 edition has 2 pages. FileIt asks for it in 6 parts:

1. Section I: Veteran's identification informationVeteran
2. Section II: Employment 1 of 4 (most recent)Veteran
3. Section II: Employment 2 of 4Veteran
4. Section II: Employment 3 of 4Veteran
5. Section II: Employment 4 of 4Veteran
6. Certification and date signedVeteran

How to fill out VA Form 21-4140, step by step

1 Section I: Veteran's identification information

Your name, Social Security number, VA file number, date of birth, service number, email, phone numbers and mailing address. Item 10 asks whether you were employed by VA, others or self-employed at any time during the past 12 months.

2 Section II: Employment certification

If you answered Yes, list all employment for the past 12 months: up to four jobs on the form. Then sign 12A and date 12B, certifying the statements are true and complete. You also confirm you understand your continued entitlement is based on the information you give VA.

3 Section III: Unemployment certification

If you answered No, sign 13A and date 13B. You certify you weren't employed in the past twelve months and that your service-connected disabilities still prevent you from securing or following gainful employment.

Common mistakes to avoid

• Signing both certifications. Sign Section II if you worked in the past 12 months, or Section III if you didn't.
• Leaving out short-term, part-time or self-employment. The form asks for all employment in the past 12 months.
• Forgetting the highest gross earnings per month for each job.
• Not returning the form when VA asks for it.

After you fill it out

Print the questionnaire, sign the certification that applies (12A or 13A) and mail it to the Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444, or complete it online as VA.gov describes. FileIt does not submit it for you.

Keep FileIt's copy in your vault with your VA award letters, and set a reminder for when VA usually asks again.

VA Form 21-4140: frequently asked questions

Official sources

• Blank form (PDF), published by U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA): https://www.vba.va.gov/pubs/forms/VBA-21-4140-ARE.pdf
• Official instructions and guidance: https://www.va.gov/find-forms/about-form-21-4140/
• Edition shown on this page: VA Form 21-4140, AUG 2024 (OMB No. 2900-0079, expires 08/31/2027) (checked 2026-10-25).

FileIt is not affiliated with or endorsed by U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-10-25.

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