What it is
VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, is a one-page questionnaire VA sends to your former employer. The employer reports your dates of employment, hours worked, gross earnings for the last 12 months, type of work, time lost due to disability, and the reason employment ended. It is the evidentiary backbone of a Total Disability Individual Unemployability (TDIU) claim under 38 CFR 4.16(a).
When you use it
You use it any time you file for TDIU on VA Form 21-8940. You list each employer from the last five years on the 21-8940; VA then mails a 21-4192 to each one. The information lets the rater decide whether your last job was substantially gainful or merely marginal employment (earnings at or below the Census Bureau poverty threshold for one person).
What to gather before you fill it out
You don't fill out 21-4192, your employer does. But before you submit 21-8940, gather: exact start and end dates for every job in the last five years, supervisor name, employer mailing address, your final job title, your last gross monthly earnings, and any documentation of accommodations, time lost, or the termination reason (separation letter, HR exit notes).
How to submit
VA mails 21-4192 directly to the employer addresses you list on 21-8940. To speed things up, download a blank 21-4192 from VA.gov, hand-deliver or email it to your former HR contact, and ask them to return it to the VA address printed on the form. Keep a copy for your C-file.
Common pitfalls
- Listing a wrong or outdated employer address. VA will mail to whatever you wrote and won't chase a bounce.
- Assuming silence kills your claim. Under VA's duty to assist, if an employer doesn't respond after a reasonable effort, the rater can decide on the rest of the record.
- Forgetting to flag accommodations. If your last job was a protected work environment (family business, sheltered job, heavily accommodated), say so on 21-8940, that pushes the rater toward a marginal-employment finding.
- Reporting current part-time income above the poverty threshold without context. Marginal employment can still be found on a facts-found basis above the threshold, but only if you raise it.
Related forms
VA Form 21-8940 (Veteran's TDIU application, required). VA Form 21-526EZ (the underlying disability claim). VA Form 21-0958 (Notice of Disagreement, legacy) or VA Form 20-0996 / 20-0995 / 10182 (decision review options).