21 4192 VBA ARE
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OMB Control No. 2900-0065 Respondent Burden: 15 minutes Expiration Date: 09/30/2020 VA DATE STAMP DO NOT WRITE IN THIS SPACE REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS 2. ADDRESS (Complete) 1. NAME AND ADDRESS OF EMPLOYER OF VETERAN (Complete) RETURN TO 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. In order to arrive at a fair decision in this case, we need the information requested below. Please complete Sections II, III and IV and return to this office at the address below. Please be sure to sign and date this form in Items 23A and 23B. For free help in completing this form, call VA toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal number is 711. SECTION I - IDENTIFICATION INFORMATION NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form. 3. VETERAN/BENEFICARY'S NAME (First, Middle Initial, Last) 4. SOCIAL SECURITY NUMBER 6. DATE OF BIRTH (MM/DD/YYYY) 5. VA FILE NUMBER (If applicable) Month Day Year SECTION II - EMPLOYMENT INFORMATION (To be completed by employer) 7. BEGINNING DATE OF EMPLOYMENT (MM/DD/YYYY) Month Day 8. ENDING DATE OF EMPLOYMENT (MM/DD/YYYY) 9. TYPE OF WORK PERFORMED Year Month Day 10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT (BEFORE DEDUCTIONS) Year 11. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT (DUE TO DISABILITY) $ 12A. NUMBER OF HOURS WORKED (Daily) 12B. NUMBER OF HOURS WORKED (Weekly) 13. CONCESSIONS (if any) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY 14A. IF VETERAN IS NOT WORKING, STATE THE REASON FOR TERMINATION OF EMPLOYMENT: (IF RETIRED ON DISABILITY, PLEASE SPECIFY) 14B. DATE LAST WORKED Month 15B. GROSS AMOUNT OF LAST PAYMENT 15A. DATE OF LAST PAYMENT Month Day 16A. WAS LUMP SUM PAYMENT MADE? YES Year Month $ 17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS? 17B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES? VA FORM SEP 2017 NO 21-4192 SUPERSEDES VA FORM 21-4192, JUL 2015, WHICH WILL NOT BE USED. Day Year 16B. DATE PAID SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS (Only complete if claimant is currently serving in the Reserve or National Guard) YES Year NO GROSS AMOUNT PAID $ Day VETERAN'S SOCIAL SECURITY NO. SECTION IV - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS (To be completed by employer) 18. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE, AS A RESULT OF HIS/HER EMPLOYMENT WITH YOU, SICK, RETIREMENT OR OTHER BENEFITS? YES NO (If "Yes," complete Items 19 through 21C) 19. TYPE OF BENEFIT 20. GROSS MONTHLY AMOUNT OF BENEFIT $ 21A. DATE BENEFIT BEGAN (MM/DD/YYYY) Month Day Year 21B. DATE FIRST PAYMENT ISSUED (MM/DD/YYYY) Month Day Year 21C. DATE BENEFIT WILL STOP (If known) (MM/DD/YYYY) Month Day Year 22. REMARKS I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief. 23A. SIGNATURE OF EMPLOYER OR SUPERVISOR (If claimant is serving in the Reserves or National Guard, then signature of unit commander or designee is required.) (Sign in ink) 23B. DATE SIGNED (MM/DD/YYYY) PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a meterial fact, knowing it to be false, or for fraudulent acceptance of any payment to which you are not entitled. PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. RESPONDENT BURDEN: We need this information to determine eligibility for disability benefits based on unemployability (38 U.S.C. 1521). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM 21-4192, SEP 2017 Page 2
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