VA Form 21-4192 Printable, Fillable in PDF

VA Form 21-4192 Printable, Fillable in PDF РVeterans Affairs Form 21-4192, Request for Employment Information in Connection with a Claim for Disability Benefits, is a document used by the United States Department of Veterans Affairs (VA) to obtain the information necessary to determine whether a veteran is eligible to receive disability benefits based on unemployability. In 2017, the form was updated to the most recent version, which was issued on September 1, 2017.

VA Form 21-4192 Printable, Fillable in PDF

Is VA Form 21-4192 of any significance? When it comes to obtaining and transmitting relevant information to the VA, this document is critical to the process. When a claim is not received by the VA, the claim will not be immediately rejected; instead, it will be reviewed based on the data that has been supplied. According to the form, the information you provide is both relevant and private. It is possible to be fined or imprisoned for knowingly submitting fraudulent declarations or evidence.

The VA Form 21-4192 And 21-8940 Are Available Online

Individuals serving in the Army who are unable to work due to their military duty are eligible for certain perks. To be eligible for these benefits, the veteran must go through the VA Disability Process. During this process, each veteran is issued a VA Disability Rating, which is used to determine the number of benefits they may be entitled to receive. The exception to the Total Rating guidelines, Individual Unemployability permits a veteran to be classified as completely handicapped if they are unable to maintain a regular and continuous source of income.

If you want to be considered for Individual Unemployability, you must complete VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. When a veteran files for complete disability compensation, it is because of service-connected physical restrictions that preclude him or her from engaging in any meaningful gainful employment.

Immediately following receipt of your application, the Department of Veterans Affairs (VA) will send VA Form 21-4192 to your current and previous employers listed in Box 16A to verify the facts and dates of employment, as well as to request information about the reason for termination of employment, among other things. It is the veteran’s obligation, however, to ensure that the form is completed and sent to the VA as quickly as possible.

VA Form 21-4192: How To Complete It

Every piece of information must be printed clearly and legibly on white paper using ink (if filing a printed-out form). The following are the instructions for completing the VA Form 21-4192.

  • Section I is where you should enter your data. Include your entire name, Social Security Number (SSN), VA file number, and date of birth in the body of your message (Boxes 3, 4, 5, and 6). If the veteran has stated that they are unable to find work in Box 1, the name and address of the employer will be included in Box 1. The “Return To” address should be included in item 2.
  • In Section II, the veteran’s employment information should be filled out by the employer, who should sign it. The starting and ending dates of the employment term are required in boxes 7 and 8. Box 9 should describe the sort of work that was done. Amounts earned for 12 months before the final employment date should be included in Box 10.
  • In Box 11, enter the amount of time you have missed because of a handicap during the previous 12 months. For each day and week the veteran works, his or her hours should be recorded in Boxes 12A and 12B by the company that employs him or her. Box 13 should include a list of any concessions provided to the employee based on his or her age or handicap.
  • The veteran’s reason for leaving their job and the date they last worked should be included if he or she is not employed (Boxes 14A and 14B). Fill out Boxes 15A and 15B with the date and gross amount of the most recent payment. If the payment was made in one lump sum, the gross amount paid as well as the date of payment should be provided in Boxes 16A and 16B of Form 1099-B.
  • If the claimant is serving in the Reserves or the National Guard, complete Section III. Other than that, don’t bother with it! The veteran’s current duty status, as well as any infirmities that restrict them from completing military tasks, should be included in this area.
  • Enter information on benefits eligibility and payments in Section IV. It is necessary to check the appropriate item in Box 18 if the veteran receives or is eligible to receive health-related benefits, pension, or other benefits. Employers will be required to give information in Boxes 19 through 21C if they get a favorable response.
  • Box 22 should be used to record any further comments you may have. The paper must be signed and stamped by the employer or supervisor.

Alternatively, if the employer has any issues filling out the form, they may contact the VA toll-free at +1 (800) 827-1000 to get assistance.

VA Form 21-4192 Printable, Fillable in PDF

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