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VA Form 21-4192

Form name:Request for Employment Information in Connection with Claim for Disability Benefits
Form revision date: August 2024
Related to: Disability

When to use this form

Use VA Form 21-4192 if you’re an employer and you need to send us information about a Veteran who’s applying for Individual Unemployability disability benefits. The Veteran’s most recent employer must complete and submit this form.

Downloadable PDF

Online tool

You can fill out VA Form 21-4192 online instead of filling out and sending us the paper form.

Related forms and instructions

VA Form 21-8940

Form name: Veteran’s Application for Increased Compensation Based on Unemployability

Use VA Form 21-8940 if you want to apply for Individual Unemployability disability benefits for a service-connected condition that prevents you from keeping a steady job.

Helpful links related to VA Form 21-4192

  • Find out if you qualify for compensation for a presumptive disability or other service-connected conditions.

  • Find out how to file a claim for disability compensation or increased disability compensation.

  • Find out if you need to complete additional forms for your disability claim.

  • Find out how to file for VA Individual Unemployability compensation if you’re an unemployed Veteran who can’t work due to a service-connected disability.

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