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

What is VA Form 21-4192?

VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, is the Department of Veterans Affairs form an employer uses to send VA information about a veteran who is claiming disability benefits. VA.gov says to use it if you're an employer and need to send information about a veteran applying for Individual Unemployability disability benefits, and that the veteran's most recent employer must complete and submit it.

Section I identifies the employer and the veteran: name, Social Security number, VA file number and date of birth. The employer completes Sections II, III and IV: the dates of employment, type of work, earnings in the 12 months before the last date of employment, time lost to disability, hours worked, any concessions made because of age or disability, why employment ended, last and lump-sum payments, Reserve or National Guard duty status if the veteran is currently serving, and any sick, retirement or other benefits the veteran receives or is entitled to because of the job.

The employer signs and dates the form (items 23A and 23B) and mails it to the Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444, as the form instructs. VA.gov also offers an online version.

FileIt guides every item in plain English and prints the answers onto VA's own official PDF (AUG 2024), splitting dates, the Social Security number and dollar amounts into the form's boxes and repeating the SSN at the top of page 2. The employer can sign with eSignature, and the finished PDF is kept in the vault. FileIt never submits anything to VA.

Who needs to fill out VA Form 21-4192?

• Employers and former employers of a veteran who has filed a VA disability claim.
• HR, payroll and benefits staff asked by VA or by a veteran to report employment details.
• Veterans applying for Individual Unemployability, who give the form to their most recent employer.
• Supervisors who can certify the veteran's hours, duties, time lost and any concessions made.
• Employers of veterans currently serving in the Reserve or National Guard (Section III).

When to use VA Form 21-4192

• When a veteran applies for Individual Unemployability with VA Form 21-8940. VA.gov says both forms are needed.
• When VA sends you the form asking for employment information about a veteran's disability claim.
• After the veteran stops working because of a disability, to report the last day worked, the reason employment ended and final payments.
• When the veteran receives, or is entitled to, sick, retirement or other benefits as a result of the employment.

What you need before you start

• The veteran's full name, Social Security number, VA file number (if any) and date of birth.
• The employer's name and address.
• Beginning and ending dates of employment and the type of work performed.
• Earnings before deductions for the 12 months before the last date of employment.
• Time lost to disability in those 12 months, and the daily and weekly hours worked.
• Any concessions made because of age or disability, such as lighter duties or a reduced schedule.
• The reason employment ended, the date last worked, and the date and gross amount of the last payment and any lump-sum payment.
• Details of any sick, retirement or other benefits: the type, gross monthly amount and the dates it began, was first paid and will stop.
• For a veteran in the Reserve or National Guard: their current duty status and whether a disability prevents them from performing military duties.

What’s on VA Form 21-4192

The 2024 edition has 2 pages. FileIt asks for it in 5 parts, and it is signed by Employer or supervisor – sections ii to iv:

1. Section I: IdentificationVeteran (or va) – section i
2. Section II: Employment informationEmployer or supervisor – sections ii to iv
3. Section III: Reserve or National Guard duty statusEmployer or supervisor – sections ii to iv
4. Section IV: Benefit entitlement and paymentsEmployer or supervisor – sections ii to iv
5. Item 22: Remarks and certificationEmployer or supervisor – sections ii to iv

How to fill out VA Form 21-4192, step by step

1 Section I: Identification (items 1–6)

Enter the employer's name and address, the address the completed form should be returned to, and the veteran's name (first, middle initial, last), Social Security number, VA file number if applicable, and date of birth. On paper the form asks for one letter per box.

2 Section II: Employment (items 7–12)

The employer gives the beginning and ending dates of employment, the type of work performed, the amount earned during the 12 months before the last date of employment (before deductions), time lost to disability during those 12 months, and the number of hours worked daily and weekly.

3 Items 13–16: Concessions, end of employment and payments

Describe any concessions made to the employee because of age or disability. If the veteran is not working, state why employment ended (and if they retired on disability, say so) and the date last worked. Give the date and gross amount of the last payment, and whether a lump-sum payment was made, with its gross amount and date paid.

4 Section III: Reserve or National Guard (item 17)

Only if the veteran is currently serving in the Reserve or National Guard: their current duty status, and whether they have any disabilities that prevent them from performing their military duties.

5 Section IV: Benefits (items 18–21)

Say whether the veteran receives or is entitled to receive sick, retirement or other benefits as a result of the employment. If yes, give the type of benefit, the gross monthly amount, the date it began, the date the first payment was issued and, if known, the date it will stop.

6 Remarks, signature and date (items 22–23)

Add any remarks. The employer or supervisor certifies the statements are true and complete to the best of their knowledge and belief, then signs (23A, required) and dates (23B) the form.

Common mistakes to avoid

• Leaving the signature blank. The form marks item 23A as required.
• Reporting earnings after deductions. Item 10 asks for the amount before deductions.
• Using the wrong period. Items 10 and 11 cover the 12 months before the last date of employment.
• Completing Section III for a veteran who isn't currently in the Reserve or National Guard.
• Answering Yes to item 18 but leaving items 19 to 21 blank.
• Mailing the form to the wrong place. The form says to mail it to the Evidence Intake Center in Janesville, Wisconsin.

After you fill it out

Sign and date items 23A and 23B, then mail the form to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444, or use VA's online version. Keep a copy for your records.

If you're the veteran, give the form to your most recent employer and file your own VA Form 21-8940. For free help completing the form, the form gives VA's toll-free number, 1-800-827-1000.

FileIt keeps the completed PDF in the vault, so the veteran or employer can find it if VA asks follow-up questions.

VA Form 21-4192: frequently asked questions

Official sources

• Blank form (PDF), published by U.S. Department of Veterans Affairs (VBA): https://www.vba.va.gov/pubs/forms/VBA-21-4192-ARE.pdf
• Official instructions and guidance: https://www.va.gov/find-forms/about-form-21-4192/
• Edition shown on this page: VA Form 21-4192, AUG 2024 (supersedes JUL 2021), OMB No. 2900-0065, expires 08/31/2027 (checked 2026-09-28).

FileIt is not affiliated with or endorsed by U.S. Department of Veterans Affairs (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 2026-09-28.

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