VA Form 21-4192 is the form VA sends to your most recent employer when you apply for individual unemployability (TDIU). You fill in only your identifying information in Section I. Your employer reports your dates of employment, earnings, time lost because of your disability, any special accommodations, and why the job ended.
Table of Contents
What Is VA Form 21-4192?
VA Form 21-4192 is officially titled Request for Employment Information in Connection with Claim for Disability Benefits. It is part of a claim for individual unemployability, also called TDIU, which pays disability compensation at the 100% rate to Veterans whose service-connected conditions keep them from working, even if their combined rating is lower than 100%.
The main TDIU application is VA Form 21-8940, where you list your recent employers. VA then uses Form 21-4192 to ask those employers to confirm what you told it: when you worked, what you earned, how much work you missed because of your disabilities, and why the job ended. The current version of the form can be completed on paper or through VA's online tool.
Who Needs to Submit Form 21-4192
Form 21-4192 is only part of a TDIU claim. To qualify for TDIU on a schedular basis under 38 CFR 4.16(a), you generally need either:
- One service-connected disability rated at 60% or more, or
- Two or more service-connected disabilities, with at least one rated at 40% or more and a combined rating of 70% or more
You also need evidence that your service-connected conditions prevent you from securing or following substantially gainful employment. Veterans who do not meet the percentage requirements can still be considered for TDIU on an extraschedular basis under 38 CFR 4.16(b) if their disabilities keep them from working. For the full eligibility rules, see our guide to TDIU eligibility and approval.
How to Fill Out VA Form 21-4192, Section by Section
The Veteran completes only the first section. The employer completes the rest and sends the form to VA.
Section I: Identification Information
This is the only section the Veteran fills out. Provide your:
- Full name, including middle initial
- Social Security number
- VA file number, if you have one
- Date of birth
Fill in every item before the form goes to your employer. Incomplete identifying information is one of the easiest ways to slow a TDIU claim down.
Section II: Employment Information
Your most recent employer completes this section. It asks for:
- Your beginning and ending dates of employment
- The type of work you performed
- The amount you earned during the 12 months before your last day of work
- Time lost during those 12 months because of disability
- The number of hours you worked each day and each week
- Any concessions the employer made because of your age or disability
- If you are no longer working there, the reason your employment ended and the date you last worked
- The date and amount of your last payment, and whether a lump-sum payment was made
Section III: Reserve or National Guard Duty Status
The employer also answers whether you are a member of the Reserve or National Guard. This section only matters if you are currently serving in the Reserve or Guard.
Section IV: Information on Benefit Entitlement and Payments
The employer reports any retirement or disability benefits you receive through the job, including the type of benefit, when it started, and when it is expected to end. The form closes with space for the employer's remarks and the employer's certification and signature. The remarks section is a chance for a supervisor to describe, in their own words, how your disability affected your work.
Why Time Lost and Concessions Matter
Two items in Section II often carry more weight than the rest of the form: time lost due to disability and concessions made because of disability.
Time lost shows how often your conditions kept you from working in the year before you stopped. Concessions show whether your employer had to make special accommodations to keep you on the job, such as a reduced schedule, extra breaks, lighter duties, or tolerance of missed days that would not be accepted from other employees. Work that exists only because an employer made those accommodations may be considered employment in a protected work environment or sheltered employment, which does not count against a TDIU claim the way ordinary work does.
Employers often leave these items blank or answer them with a single word. If your supervisor knows how much help you needed, ask them to be specific in these items and in the remarks section.
What If Your Employer Won't Complete Form 21-4192?
This is one of the most common problems in TDIU claims. Employers ignore the form, send it to the wrong office, or have closed their doors. A missing Form 21-4192 does not by itself stop VA from granting TDIU, but it can delay the claim and leave gaps in the evidence.
VA has a duty to try. Under 38 CFR 3.159(c)(1), VA must make reasonable efforts to get records from current or former employers, which generally means an initial request and, if the records do not arrive, at least one follow-up. If VA still cannot get the information, it must tell you what it could not obtain and that it will decide the claim on the evidence it has unless you provide it.
You can fill the gap yourself. Evidence that can substitute for, or add to, Form 21-4192 includes:
- Pay stubs, W-2s, and tax returns showing your earnings and when they stopped
- A Social Security earnings statement
- Termination, discipline, or leave letters that mention your health or attendance
- Records of accommodations, FMLA leave, or disability benefits through the employer
- Your own detailed statement about why you stopped working
- Lay statements from former coworkers or supervisors describing how your disabilities affected your work
If the business has closed, tell VA that in writing and submit whatever employment records you have. Statements from former coworkers can be especially useful, because they can describe what the employer would have reported.
If your TDIU claim was denied because VA said it lacked employment information, that is often fixable with a Supplemental Claim that includes the missing evidence. An attorney can review the decision and tell you what the record is missing.
Self-Employed Veterans
Form 21-4192 is designed for an outside employer, so it generally does not apply to your own business. If you were self-employed, you will usually show your work history and earnings through tax returns, business records, and a detailed statement about how your disabilities affected the business. See our FAQ on getting TDIU when you are self-employed.
Frequently Asked Questions
What is VA Form 21-4192?
VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, is the form VA uses to get employment information from a veteran's most recent employer when the veteran applies for individual unemployability (TDIU). The employer reports dates of employment, earnings, time lost due to disability, any concessions made because of disability, and why the job ended.
Who fills out VA Form 21-4192?
The veteran completes Section I with identifying information. The veteran's most recent employer completes the rest of the form, including employment information, Reserve or National Guard status, and any retirement or disability benefits paid by the employer. VA usually sends the form to the employers the veteran lists on VA Form 21-8940.
What if my employer won't fill out Form 21-4192?
VA must make reasonable efforts to get records from former employers, which generally means an initial request and at least one follow-up. If the employer still does not respond, VA must tell you and will decide the claim on the evidence it has unless you provide the information. You can submit substitute evidence such as pay stubs, W-2s, tax returns, a Social Security earnings statement, termination or discipline letters, and your own statement or statements from coworkers.
What if my former employer is out of business?
Tell VA the business has closed and submit whatever employment evidence you have, such as W-2s, tax returns, a Social Security earnings statement, and statements from former coworkers or supervisors describing your work and how your disability affected it. A missing Form 21-4192 does not by itself prevent VA from granting TDIU.
Do I need Form 21-4192 if I was self-employed?
Form 21-4192 is designed for an outside employer, so it generally does not apply to your own business. Self-employed veterans usually show their work history and earnings through tax returns, business records, and a detailed personal statement about how their disabilities affected the business.
Get Help With Your TDIU Claim
TDIU claims are often decided on the employment record, and Form 21-4192 is a big part of it. If your claim is stalled because an employer won't respond, or it was denied for lack of employment evidence, the Law Office of Sean Kendall can review your file and help you build the record. We represent Veterans nationwide on a contingency-fee basis, so you pay no attorney fee unless we win benefits for you. Call (877) 629-1712 toll-free or (303) 449-4773, or request a free case review.
