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Click ‘Get Form’ to open VA Form 21-4192 in the editor.
Begin by filling out Section I, which includes the veteran's name, address, social security number, and date of birth. Ensure all information is accurate and complete.
Proceed to Section II for employment information. The employer should provide details such as the beginning and ending dates of employment, type of work performed, and earnings during the last twelve months.
In Section III, if applicable, indicate the veteran's current duty status and any disabilities that may affect their military duties.
Complete Section IV regarding benefit entitlement. Employers must specify if the veteran receives any benefits related to their employment.
Finally, ensure that the employer signs and dates the form in Items 23A and 23B before submitting it.
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What if my employer wont fill out the VA form 21-4192?
Applying for VA unemployability benefits can be a complex and arduous process, with many veterans facing denials for their claims.
What is VA form 21-4192 used for?
The VA cant deny your unemployability claim if your former employer fails to complete VA Form 21-4192. The form is not absolutely necessary to receive a favorable decision on your TDIU claim. Many veterans have succeeded with their TDIU claim without a 21-4192. However, without the form, the process could be delayed.
Do you have to file for TDIU?
To receive TDIU benefits, the veteran must apply for disability compensation and fill out two additional forms: Veterans Application for Increased Compensation Based on Unemployability (Form 21-8940) Request for Employment Information in Connection with Claim for Disability Benefits (Form 21-4192)
Does the VA contact previous employers Tdiu?
If you decide to file a TDIU claim, youll need to submit a VA Form 21-8940. Based on the information you provide in Form 21-8940, the VA will automatically generate and send a VA Form 21-4192 to your most recent employer. The VA will send you a copy as well.
Who can help me fill out VA forms?
An accredited attorney, claims agent, or Veterans Service Organization (VSO) representative can help you file a claim or request a decision review. Learn how to find and appoint one of these types of accredited representatives to help you.
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Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.
Do I need to fill out VA form 21-4192?
When to use this form. Use VA Form 21-4192 if youre a Veteran and you need your most recent employer to send us information so you can apply for Individual Unemployability disability benefits. Your most recent employer must complete and submit this form.
21 4192
Employment Information in Connection with Claim for
INSTRUCTIONS: The veteran named in Item 3 has filed a claim for veterans disability benefits and has stated that he/she was recently employed by you.
VA Form 21-4142 Authorization to Disclose Information to VA VA Form 21-4142a Release for Medical Provider Information to VA VA Form 21-4192 Request for
Mar 14, 2025 Find out if you qualify for compensation for a presumptive disability or other service-connected conditions. How to file a VA disability claim.
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