VA Form 21-4192
Request for Employment Information in Connection with Claim for Disability Benefits
You filed (or are about to file) for TDIU (21-8940) and want to provide employer verification alongside your claim instead of waiting for VA to contact the employer separately.
- Who fills it
- employer
- Journey phase
- Evidence & Statements
- Estimated time
- 10-15 minutes for the veteran to request from employer; employer typically completes in 20-30 minutes.
- When to file
- Submit with your 21-8940 TDIU claim or in response to a VA development letter requesting employment information.
Official VA form page: https://www.va.gov/find-forms/about-form-21-4192/
Gather before you start
- ▸Former employer's name, address, HR/payroll contact
- ▸Your dates of employment (start and last day worked)
- ▸Your position/job title at that employer
- ▸Reason you left (medical, layoff, performance, etc.) - be consistent with 21-8940 Section III
- ▸Gross wages and hours per week during last period of employment
Attach with the form
- ▸Completed VA Form 21-4192 signed by employer
- ▸Cover letter to employer explaining what VA needs (optional but helpful)
What to Tell Your Former Employer
Brief 1How to request this from your employer
Contact HR or payroll at your most recent employer. Explain you are filing a VA disability claim and need them to complete VA Form 21-4192. Provide them the blank form and a cover letter. Employers are federally required to cooperate with VA employment-record requests under 38 USC 5103A. Most will complete within 1-2 weeks if you ask directly.
(talking points for requesting from employer)
Common mistakes
- ×Waiting for VA to send the form to the employer - VA typically takes weeks to mail it; submitting a pre-completed copy is much faster.
- ×Asking the wrong person (receptionist vs. HR) - always contact HR or payroll specifically for employment verification.
Authority
- 38 CFR 4.16 - Schedular TDIU: 1 disability ≥60% OR multiple disabilities w/ combined ≥70% incl. one ≥40%; extra-schedular under 4.16(b).
Review Employer's Completed Form Before Submitting
Brief 2Verify accuracy of employer's answers
Before submitting the completed form to VA, verify these fields match what you reported on 21-8940: (1) Employment dates match Section III of your 21-8940, (2) Reason for separation matches what you stated, (3) Wages and hours are accurate, (4) Job duties are described accurately. Any discrepancy between 21-8940 and 21-4192 will be flagged by the rater.
(cross-reference checklist with your 21-8940)
Common mistakes
- ×Submitting without reviewing - employer HR departments sometimes enter incorrect dates or vague reasons for leaving.
- ×Discrepancy between your stated reason (21-8940: "unable to perform due to disability") and employer's stated reason ("resigned") - contact employer to correct before submitting.
Employer Signature Requirement
Brief 3Confirm employer signed and dated
The form is only valid with an authorized employer representative's signature, printed name, title, and date. HR Director, Payroll Manager, or Personnel Officer are typical authorized signers. A general employee or front-desk signature is not sufficient.
(verify authorized signature)
Common mistakes
- ×Submitting without an authorized signature - VA will request a new completion from the employer.
- ×Date missing from employer signature - VA returns for completion.
Statutory and regulatory authority
- 38 CFR 4.16 - Schedular TDIU: 1 disability ≥60% OR multiple disabilities w/ combined ≥70% incl. one ≥40%; extra-schedular under 4.16(b).
- M21-1 IV.ii.3.E - How raters apply 38 CFR 4.16(a) and 4.16(b).