OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 2900-0065 · VA.

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. Without this information, determination of entitlement would not be possible.

The latest form for Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) expires 2027-08-31 and is listed under ICR 202404-2900-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)Form
30-DAY FRN 2900-0065.pdf Supplementary Document
2024-09378, 60-Day FRN (VAF21-4192).pdf Supplementary Document
2900-0065, Supporting Statement (VAF21-4192) (2).docxSupporting Statement A
Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202404-2900-001 Revision of a currently approved collection 2024-07-08 Approved without change
202009-2900-010 Reinstatement with change of a previously approved collection 2021-05-20 Approved without change
201612-2900-016 Extension without change of a currently approved collection 2017-06-08 Approved with change
201405-2900-008 Revision of a currently approved collection 2014-09-02 Approved without change
201305-2900-012 Extension without change of a currently approved collection 2013-09-20 Approved without change
201009-2900-020 Extension without change of a currently approved collection 2010-12-23 Approved without change
200707-2900-015 Extension without change of a currently approved collection 2007-11-14 Approved without change
200408-2900-007 Extension without change of a currently approved collection 2004-08-19 Approved without change
200107-2900-003 Extension without change of a currently approved collection 2001-07-13 Approved without change
199808-2900-009 Reinstatement without change of a previously approved collection 1998-08-19 Approved without change
199508-2900-029 Extension without change of a currently approved collection 1995-08-28 Withdrawn and continue
199305-2900-004 Revision of a currently approved collection 1993-05-19 Approved without change
199007-2900-003 Extension without change of a currently approved collection 1990-07-13 Approved without change
198904-2900-021 No material or nonsubstantive change to a currently approved collection 1989-04-04 Approved with change
198706-2900-007 Revision of a currently approved collection 1987-06-16 Approved without change
198608-2900-026 No material or nonsubstantive change to a currently approved collection 1986-08-08 Approved with change
198408-2900-010 Reinstatement with change of a previously approved collection 1984-08-06 Approved without change
198107-2900-040 No material or nonsubstantive change to a currently approved collection 1981-07-17 Approved with change
198006-2900-015 Revision of a currently approved collection 1980-06-06 Approved without change
198003-2900-004 Revision of a currently approved collection 1980-03-04 Withdrawn and continue
197610-2900-002 Revision of a currently approved collection 1976-10-07 Approved without change