Get VA 21-4192 2021-2024
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 21A and 21B. For free help in completing this form call VA toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf TDD the Federal number is 711. 3. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN 4. SOCIAL SECURITY NO. 5. VA FILE NO. SECTION II - EMPLOYMENT INFORMATION To be completed by employer 6. BEGINNING DATE OF EMPLOYMENT Month Day 7. ENDING DATE OF EMPLOYMENT Year 8. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT BEFORE DEDUCTIONS 9. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT DUE TO DISABILITY 10. TYPE OF WORK PERFORMED 11. NUMBER OF HOURS WORKED B. WEEKLY A. DAILY 12. CONCESSIONS IF ANY MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY 13A. IF VETERAN IS NOT WORKING STATE REASON FOR TERMINATION OF EMPLOYMENT IF RETIRED ON DISABILITY PLEASE SPECIFY 14B. GROSS AMOUNT OF LAST PAYMENT 14A. DATE OF LAST PAYMENT 13B. DATE LAST WORKED 15A. WAS LUMP SUM PAYMENT MADE 15C. SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS Only complete if claimant is currently serving in the Reserve or National Guard 16A. WHAT IS THE VETERAN S CURRENT DUTY STATUS 16B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES SECTION IV - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS To be completed by employer 17. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE AS A RESULT OF HIS/HER EMPLOYMENT WITH YOU SICK RETIREMENT OR OTHER BENEFITS 18. TYPE OF BENEFIT 19. GROSS MONTHLY AMOUNT OF BENEFIT 20A. DATE BENEFIT BEGAN 20B. DATE FIRST PAYMENT ISSUED 21A. SIGNATURE OF EMPLOYER OR SUPERVISOR If claimant is serving in the Reserves or National Guard then signature of unit commander or designee is required 21B. DATE SIGNED PRIVACY ACT NOTICE VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38 Code of Federal Regulations 1. 576 for routine uses i*e* civil or criminal law enforcement congressional communications epidemiological or research studies the collection of money owed to the United States litigation in which the United States is a party or has an interest the administration of VA programs and delivery of VA benefits verification of identity and status and personnel administration as identified in the VA system of records 58VA21/22/28 Compensation Pension Education and Vocational Rehabilitation and Employment Records - VA published in the Federal Register.
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