VA Form 21-4192: Complete Guide for TDIU Claims

What Is VA Form 21-4192?

VA Form 21-4192, “Request for Employment Information in Connection with Claim for Disability Benefits,” is a form your former employer completes to provide the VA with employment information needed for your Total Disability based on Individual Unemployability (TDIU) claim . It documents your work history, earnings, and why you stopped working, helping the VA determine if you qualify for compensation at the 100% disability rate due to being unable to work .

Quick Facts

What Is VA Form 21-4192 Used For?

VA Form 21-4192 is used to gather employment information from a Veteran’s former employers so the VA can determine eligibility for increased disability benefits based on Individual Unemployability . When you apply for TDIU using VA Form 21-8940, the VA sends Form 21-4192 to your most recent employer(s) to verify your work history and the circumstances under which you left employment .

What the form asks employers :

• Dates of employment

• Type of work performed

• Earnings during the 12 months before leaving

• Hours worked per day and week

• Time lost due to disability

• Reason for termination

• Any benefits received (sick leave, retirement pay)

What Is TDIU?

Total Disability Based on Individual Unemployability (TDIU) is a benefit that provides disability compensation equal to a 100% rating to Veterans who are unable to work due to their service-connected disabilities . You may qualify even if your combined rating is below 100%.

To qualify for TDIU, you must show:

• You are unable to obtain and maintain substantially gainful employment

• Your inability to work is due to service-connected conditions

• You meet the criteria under 38 CFR § 4.16 

How to Complete VA Form 21-4192

If You Are the Veteran

The employer fills out most of this form, but you can help by completing Section I first .

Section I: Identification Information
Fill in your:

• Name

• VA file number

• Social Security number

• Date of birth

Box 1: Enter your former employer’s name and address
Box 2: Enter the VA Evidence Intake Center address :

Department of Veterans Affairs
Evidence Intake Center
P.O. Box 4444
Janesville, WI 53547-4444

Give the form to your former employer. They will complete Sections II, III, and IV and mail it back to the Evidence Intake Center .

If You Are the Employer

Complete Sections II, III, and IV accurately.

Section II: Employment Information :

• Beginning and ending dates of employment

• Type of work performed

• Amount earned in the 12 months before leaving

• Time lost due to disability

• Hours worked daily and weekly

• Reason for termination

• Date and amount of last payment

Section III: Reserve or National Guard Status (if applicable) :

• Current duty status

• Whether disabilities prevent military duty performance

Section IV: Benefit Entitlement :

• Sick, retirement, or other benefits received

• Monthly amount and dates

Where to Mail VA Form 21-4192

Phone: 1-800-827-1000 (Veterans Benefits) 

Common Challenges and How to Handle Them

My Former Employer Is Out of Business

If your employer is no longer in business, tell the VA. The VA will still send the form, but you should inform them that the information is unavailable. This may not prevent your TDIU claim, but it helps the VA understand why the form wasn’t returned .

My Employer Won’t Release Information

Some employers won’t release employment information without your consent. Call your former employer and ask if they need a consent form signed. Let the VA know if the employer is uncooperative .

I Received the Form but Applied Online

If you filed your claim online, you don’t need to submit the PDF. The VA asks you questions about your employment history as part of the online TDIU claim process .

Tips for a Successful VA Form 21-4192 Submission

• Complete Section I accurately—errors can delay processing

• Provide correct employer contact information so the VA can reach them

• Notify the VA immediately if an employer is out of business

• Follow up if the VA hasn’t received the form in a few weeks

• Keep copies of everything you send to the VA

Common Questions

1. What is VA Form 21-4192 used for?

VA Form 21-4192 collects employment information from your former employer to help the VA decide if you qualify for TDIU benefits due to being unable to work from service-connected disabilities .

2. Who fills out VA Form 21-4192?

Your most recent employer fills out Sections II, III, and IV. The Veteran completes Section I with identification and employer address information .

3. What is TDIU and why does the VA need this form?

TDIU (Total Disability Based on Individual Unemployability) is a benefit that pays Veterans at the 100% rate when they can’t work due to service-connected conditions. The VA needs employment history to determine if you qualify .

4. How do I submit VA Form 21-4192?

Mail the completed form to the VA Evidence Intake Center at P.O. Box 4444, Janesville, WI 53547-4444. If you filed your claim online, you may not need to submit the PDF—the VA will ask you questions directly .

5. What if my former employer is no longer in business?

Inform the VA that the employer is out of business and the information is unavailable. The VA will take this into account when processing your claim .

6. What information does the employer provide on Form 21-4192?

The employer provides dates of employment, type of work, earnings, hours worked, time lost due to disability, reason for termination, and any benefits received .

7. Is VA Form 21-4192 required for TDIU?

The form is required to obtain TDIU benefits, but if the employer is unavailable, the VA may proceed without it. The Veteran should notify the VA if the form cannot be obtained .

8. What if I get the form directly from the VA?

If the VA sends you Form 21-4192, fill in your identification information, enter your employer’s name and address in Box 1, and the Evidence Intake Center address in Box 2, then deliver it to your former employer .

9. Do I need to complete VA Form 21-4192 if I apply online?

No. If you file a TDIU claim online, the VA will ask you employment questions during the application process instead of requiring you to submit the PDF .

10. Where do I mail the completed form?

Mail to the Department of Veterans Affairs Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444 .

11. Does VA Form 21-4192 have a filing deadline?

It should be submitted as soon as possible after filing your TDIU claim. Delays can affect the processing of your claim.

12. What happens if the employer doesn’t return the form?

The VA may try to contact the employer again. If the information cannot be obtained, the VA may decide your claim based on the available evidence, but it’s best to notify them if the employer is unreachable .

Key Takeaways

• VA Form 21-4192 is for TDIU claims—your former employer provides employment history to help the VA determine if you qualify for 100% compensation 

• You complete Section I, the employer completes Sections II, III, and IV 

• Mail to the Evidence Intake Center at P.O. Box 4444, Janesville, WI 53547-4444 

• Not required if you apply online—the VA will ask you employment questions directly 

• Call 1-800-827-1000 for help completing the form 

• Notify the VA if your former employer is out of business or uncooperative 

• Form revision date is August 2024—always use the current version 

Official Resources

• VA Form 21-4192 Download: VA.gov/forms

• VA Form 21-8940 (TDIU Application): VA.gov/forms

• File a Disability Claim Online: VA.gov/disability/how-to-file-claim

• VA Benefits Hotline: 1-800-827-1000

• USA.gov: USA.gov

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