Form 21-4140 Employment Questionnaire

OMB Approved No. 2900-0079
Respondent Burden: 5 minutes
Expiration Date: X/XX/XXXX
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)

EMPLOYMENT QUESTIONNAIRE
INSTRUCTIONS: You are receiving compensation at the 100 percent rate based on being unable to secure or follow a
substantially gainful occupation as a result of your service-connected disabilities. If you were self-employed or employed
by others, including the Department of Veterans Affairs, at any time during the past 12 months, complete Section II of this
form. If you have not been employed during the past 12 months, complete Section III of this form.
DATE MAILED

STATION
ADDRESS

SECTION I-VETERAN'S IDENTIFICATION INFORMATION

NOTE: You can either complete the form online or by hand. Please print the information required in ink, neatly, and legibly to help process the form.

1. NAME OF VETERAN (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

5. VETERAN'S SERVICE NUMBER (If applicable)

4. DATE OF BIRTH (MM/DD/YYYY)

6. E-MAIL ADDRESS (Optional)

7. PRIMARY TELEPHONE NUMBER (Include Area Code)

8. ALTERNATE TELEPHONE NUMBER (Include Area Code)

9. COMPLETE ADDRESS OF VETERAN OR CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

10. WERE YOU EMPLOYED BY VA, OTHERS OR SELF EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS? (If "Yes,"
complete Section II only, if "No," complete Section III only)
YES
NO
SECTION II-EMPLOYMENT CERTIFICATION
List all employment for the past 12 months
11A. NAME AND ADDRESS OF EMPLOYER
(If self-employed, write "self")

VA FORM
XXX XXXX

21-4140

11B. TYPE
OF WORK

11C. HOURS
PER WEEK

11D. DATES OF EMPLOYMENT 11E. TIME 11F. HIGHEST
GROSS
OR SELF-EMPLOYMENT
LOST FROM
EARNINGS
ILLNESS
PER MONTH
TO
FROM

EXISTING STOCKS OF VA FORM 21-4140-1, AUG 2011,
WILL BE USED.

VETERAN'S SOCIAL SECURITY NO.

SECTION II-EMPLOYMENT CERTIFICATION (Continued)
11A. NAME AND ADDRESS OF EMPLOYER
(If self-employed, write "self")

11B. TYPE
OF WORK

11C. HOURS
PER WEEK

11D. DATES OF EMPLOYMENT 11E. TIME 11F. HIGHEST
GROSS
OR SELF-EMPLOYMENT
LOST FROM
EARNINGS
ILLNESS
PER MONTH
TO
FROM

I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief.
I UNDERSTAND THAT my continued entitlement to VA unemployability compensation benefits will be based on information that I have furnished
on this form or that I hereafter may be required to furnish VA.
12A. SIGNATURE OF VETERAN (REQUIRED)

12B. DATE SIGNED (MM/DD/YYYY)

SECTION III-UNEMPLOYEMENT CERTIFICATION
Complete this section if you did NOT work during the past 12 months

I CERTIFY THAT I have not been employed by VA, others or self-employed during the past twelve months.
I FURTHER CERTIFY THAT the items completed on this form are true and correct to the best of my knowledge and belief. I believe that my
service-connected disability(ies) has not improved and continues to prevent me from securing or following gainful employment.
13A. SIGNATURE OF VETERAN (REQUIRED)

13B. 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 material 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 required to obtain or retain benefits. 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 continued eligibility to compensation at the 100 percent rate based on individual unemployability (38
CFR 4.16). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 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
XXX XXXX

21-4140

EXISTING STOCKS OF VA FORM 21-4140-1, AUG 2011,
WILL BE USED.