Form 21-4192 Request for Employment Information in Connection with Cl

OMB Approved No. 2900-0065
Respondent Burden: 15 minutes

REQUEST FOR EMPLOYMENT INFORMATION
IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS
SECTION I - IDENTIFICATION INFORMATION (To be completed by VA)

.

1. NAME AND ADDRESS OF EMPLOYER OF VETERAN (Complete)

.

2. ADDRESS (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 and III and return to this office at the above address.
Please be sure to sign and date this form in Items 21A and 21B. FOR FREE HELP IN COMPLETING THIS FORM, CALL VA TOLL-FREE: 1-800-827-1000
(TDD 1-800-829-4833).
3. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN

4. SOCIAL SECURITY NO.

5. VA FILE NO.

SECTION II - EMPLOYMENT INFORMATION (To be completed by employer)
6. BEGINNING DATE OF
EMPLOYMENT

7. ENDING DATE OF
EMPLOYMENT

8. AMOUNT EARNED DURING 12 MONTHS PRECEDING
LAST DATE OF EMPLOYMENT (BEFORE DEDUCTIONS)

9. TIME LOST DURING 12 MONTHS PRECEDING
LAST DATE OF EMPLOYMENT (DUE TO
DISABILITY)

$
10. TYPE OF WORK PERFORMED

11. NUMBER OF HOURS WORKED
A. DAILY

B. WEEKLY

12. CONCESSIONS (IF ANY) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY

13A. IF VETERAN IS NOT WORKING, STATE REASON FOR TERMINATION OF
EMPLOYMENT. IF RETIRED ON DISABILITY, PLEASE SPECIFY.

13B. DATE LAST
WORKED

14A. DATE OF LAST PAYMENT

14B. GROSS AMOUNT OF LAST PAYMENT

$
15A. WAS LUMP SUM PAYMENT MADE?

YES

NO

15B. GROSS AMOUNT PAID

15C. DATE PAID

(If "Yes," complete Items 15B and 15C)

SECTION III - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS(To be completed by employer)
16. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE, AS A RESULT OF
HIS/HER EMPLOYMENT WITH YOU, SICK, RETIREMENT OR OTHER
BENEFITS?
(If "Yes," complete Items 17 and 20)
YES
NO
18. GROSS MONTHLY AMOUNT OF BENEFIT
19A. DATE BENEFIT
BEGAN

17. TYPE OF BENEFIT

19B. DATE FIRST PAYMENT
ISSUED

21A. SIGNATURE OF EMPLOYER OR SUPERVISOR

20. DATE BENEFIT WILL STOP (If known)

21B. DATE

Privacy Act Notice: The 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, Compensation, Pension, Education and
Rehabilitation 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.
Important Notice About Information Collection: 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.whitehouse.gov/omb/library/OMBINV.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this
form.
VA FORM
JUL 2004

21-4192

SUPERSEDES VA FORM 21-4192, DEC 1994,
WHICH WILL NOT BE USED.