21 4192 VBA ARE
User Manual: 4192
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7. BEGINNING DATE OF EMPLOYMENT (MM/DD/YYYY)
SECTION I - IDENTIFICATION INFORMATION
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.
REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR
DISABILITY BENEFITS
OMB Control No. 2900-0065
Respondent Burden: 15 minutes
Expiration Date: 09/30/2020
2. ADDRESS (Complete)
1. NAME AND ADDRESS OF EMPLOYER OF VETERAN (Complete)
8. ENDING DATE OF EMPLOYMENT (MM/DD/YYYY)
10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF
EMPLOYMENT (BEFORE DEDUCTIONS)
11. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT
(DUE TO DISABILITY)
9. TYPE OF WORK PERFORMED
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
$
VA FORM
SEP 2017 21-4192 SUPERSEDES VA FORM 21-4192, JUL 2015,
WHICH WILL NOT BE USED.
RETURN
TO
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
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.
6. DATE OF BIRTH (MM/DD/YYYY)
4. SOCIAL SECURITY NUMBER 5. VA FILE NUMBER (If applicable)
3. VETERAN/BENEFICARY'S NAME (First, Middle Initial, Last)
YearDayMonth
SECTION II - EMPLOYMENT INFORMATION (To be completed by employer)
YearDayMonth YearDayMonth
14A. IF VETERAN IS NOT WORKING, STATE THE REASON FOR TERMINATION OF EMPLOYMENT:
(IF RETIRED ON DISABILITY, PLEASE SPECIFY)
14B. DATE LAST WORKED
YearDayMonth
15A. DATE OF LAST PAYMENT
YearDayMonth
15B. GROSS AMOUNT OF
LAST PAYMENT
$
16A. WAS LUMP SUM PAYMENT
MADE?
YES NO
GROSS AMOUNT PAID YearDayMonth
16B. DATE PAID
$
SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS
(Only complete if claimant is currently serving in the Reserve or National Guard)
17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?
17B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES?
YES NO
20. GROSS MONTHLY AMOUNT OF BENEFIT
18. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE, AS A RESULT OF HIS/HER EMPLOYMENT WITH YOU, SICK, RETIREMENT OR OTHER BENEFITS?
YES NO
19. TYPE OF BENEFIT
I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief.
21C. DATE BENEFIT WILL STOP (If known)
(MM/DD/YYYY)
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)
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.
(If "Yes," complete Items 19 through 21C)
$
VA FORM 21-4192, SEP 2017
SECTION IV - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS (To be completed by employer)
21A. DATE BENEFIT BEGAN (MM/DD/YYYY) 21B. DATE FIRST PAYMENT ISSUED (MM/DD/YYYY)
YearDayMonth YearDayMonth YearDayMonth
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.
22. REMARKS
VETERAN'S SOCIAL SECURITY NO.
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