DATE PAID YES VA FORM JUL 2015 NO If Yes complete Items 15B and 15C 21-4192 SUPERSEDES VA FORM 21-4192 DEC 2010 WHICH WILL NOT BE USED. Reginfo. gov/public/do/PRAMain. If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM 21-4192 JUL 2015. OMB Control No* 2900-0065 Respondent Burden 15 minutes Expiration Date 11/30/2017 REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS SECTION I - IDENTIFICATION INFORMATION To be completed by VA. 1. NAME AND ADDRESS OF EMPLOYER OF VETERAN Complete 2. ADDRESS Complete RETURN TO INSTRUCTIONS The veteran named in Item 3 has filed a claim for veterans disability benefits and has stated that he/she was recently employed by you. In order to arrive at a fair decision in this case we need the information requested below. Please complete Sections II III and IV and return to this office at the above address. Please be sure to sign and date this form in Items 2....
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How to fill out the VA 21-4192 online
The VA 21-4192 form is essential for veterans seeking to provide employment information related to a claim for disability benefits. This guide will assist you in completing the form online, ensuring that you provide all necessary details accurately and efficiently.
Follow the steps to successfully complete the VA 21-4192 form online.
- Click ‘Get Form’ button to retrieve the VA 21-4192 form and open it in your selected editor.
- Begin by entering the name and address of the employer of the veteran in the designated fields. Ensure that you provide complete and accurate information.
- Fill in the veteran or beneficiary's name, social security number, date of birth, and VA file number if applicable in Section I.
- In Section II, the employer must provide employment information, including the beginning and ending dates of employment, type of work performed, and the amount earned during the previous 12 months.
- Indicate any time lost due to disability and specify the number of hours worked daily and weekly. If any concessions were made to the employee because of age or disability, detail those as well.
- If the veteran is no longer employed, state the reason for termination and the date they last worked. Additionally, record information about any last payments such as the gross amount and dates.
- Complete Section III if the claimant is currently serving in the Reserve or National Guard, providing current duty status and any disabilities preventing military duties.
- In Section IV, the employer should specify if the veteran is receiving or entitled to any benefits from their employment and provide details about those benefits.
- Finally, ensure that the employer or supervisor signs and dates the form in the specified areas. Verify that all information is true and complete.
- Once you have ensured all sections are filled out correctly, save the changes, and proceed to download, print, or share the form as needed.
Start your process by filling out the VA 21-4192 online today!
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