Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)

OMB 2900-0065

VA Form 21-4192 is used to gather necessary employment information from Veterans' employers so VA can determine eligibility to increased disability benefits based on unemployability.

The latest form for Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) expires 2020-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) Form
2021-10295, 30-Day FRN (2900-0065).pdf Supplementary Document
2021-04901, 60-Day FRN (2900-0065).pdf Supplementary Document
2900-0065, Supporting Statement (VAF 21-4192).docx Supporting Statement A
Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) Form

All Historical Document Collections

202009-2900-010 Approved without change	Reinstatement with change of a previously approved collection	2021-05-20
201612-2900-016 Approved with change	Extension without change of a currently approved collection	2017-06-08
201405-2900-008 Approved without change	Revision of a currently approved collection	2014-09-02
201305-2900-012 Approved without change	Extension without change of a currently approved collection	2013-09-20
201009-2900-020 Approved without change	Extension without change of a currently approved collection	2010-12-23
200707-2900-015 Approved without change	Extension without change of a currently approved collection	2007-11-14
200408-2900-007 Approved without change	Extension without change of a currently approved collection	2004-08-19
200107-2900-003 Approved without change	Extension without change of a currently approved collection	2001-07-13
199808-2900-009 Approved without change	Reinstatement without change of a previously approved collection	1998-08-19
199508-2900-029 Withdrawn and continue	Extension without change of a currently approved collection	1995-08-28
199305-2900-004 Approved without change	Revision of a currently approved collection	1993-05-19
199007-2900-003 Approved without change	Extension without change of a currently approved collection	1990-07-13
198904-2900-021 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-04-04
198706-2900-007 Approved without change	Revision of a currently approved collection	1987-06-16
198608-2900-026 Approved with change	No material or nonsubstantive change to a currently approved collection	1986-08-08
198408-2900-010 Approved without change	Reinstatement with change of a previously approved collection	1984-08-06
198107-2900-040 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-07-17
198006-2900-015 Approved without change	Revision of a currently approved collection	1980-06-06
198003-2900-004 Withdrawn and continue	Revision of a currently approved collection	1980-03-04
197610-2900-002 Approved without change	Revision of a currently approved collection	1976-10-07