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April 13, 2023

VA Form 21-4192: A Quick Guide for Veterans

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The VA Form 21-4192 is a VA request for employment information from your most recent employer. It’s typically submitted alongside a few other forms when a veteran wants to file a VA unemployability claim, also known as Total Disability Individual Unemployability (TDIU). The VA uses this form to help evaluate your claim and decide if you need increased disability compensation based on unemployability. 

VA FORM 21 4192


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Who fills out VA Form 21-4192?

If you decide to file a TDIU claim, you’ll need to submit a VA Form 21-8940. Based on the information you provide in Form 21-8940, the VA will automatically generate and send a VA Form 21-4192 to your most recent employer. 

The VA will send you a copy as well. At that point, it’s a good idea to work with your former employer directly to make sure they complete and submit the form on time.

How to complete VA Form 21-4192

Once you receive your copy, fill out only the top part and section I. Your former employer completes all other sections. Then, you can mail it or hand-deliver it to your former employer. 

From there, it’s up to them to complete and submit the form to the VA. However, nothing is stopping you from mailing the form on behalf of your former employer. Doing so could potentially speed up the process.

One thing to note: It’s a good idea to reach out and see if your former employer requires a privacy waiver before they can complete the form.

If the VA receives the completed VA Form 21-4192 within 15 days, they will refer your claim to rating. If it takes longer than 15 days, they will send a follow-up letter to your former employer and grant a 15-day extension.

Inform the VA immediately if your previous employer is no longer in business. If you haven’t yet filed a TDIU claim and are still filling out VA Form 21-8940, be sure to note on your 21-8940 if a former employer is no longer in business.


How to fill out your part of VA Form 21-4192

You’ll start by filling out the top blocks. Write your former employer’s address in block one and the address of the VA Evidence Intake Center in block two:

PO BOX 4444
JANESVILLE, WI 53547-4444

Next, fill out section I with your personal information. You’ll need your:

  • Name
  • Social Security number
  • VA file number
  • Date of birth

*Your former employer should complete sections II-IV.


What if my former employer won’t fill out VA Form 21-4192?

The VA can’t deny your unemployability claim if your former employer fails to complete VA Form 21-4192. The form is not absolutely necessary to receive a favorable decision on your TDIU claim. 

Many veterans have succeeded with their TDIU claim without a 21-4192. However, without the form, the process could be delayed. The VA considers it your responsibility to get the required information. You’ll want to stay ahead of the game and check in until you’re sure your former employer has submitted the form.

Your former employer may refuse to fill out VA Form 21-4192. In fact, this has happened to many veterans. Sometimes businesses fear setting themselves up for a lawsuit for failing to make accommodations for your service-connected disability. Or maybe you left on not-so-good terms. Whatever their reason, there are ways around this.

The best thing to do is notify the VA as soon as possible. Often, the VA will continue processing your claim without a completed VA Form 21-4192. You can also complete the entire form yourself and attach an addendum or a letter explaining that, despite your efforts, your former employer refuses to sign the form. 

DO NOT sign for your former employer. That could be considered fraud. Simply fill out all sections truthfully and leave the signature block blank, or below it, write “Employer refuses to sign.”

We’ve Got Your Six

The many rules, regulations, forms, and policies make navigating the VA claims process intimidating. But YOU DESERVE to maximize your VA benefits. We’re here to support you if you’re considering filing a TDIU claim. Our Veteran Coaches are available and can help guide you through the process. 



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Our process takes the guesswork out of filing a VA disability claim and supports you every step of the way in building a fully-developed claim (FDC)—so you can increase your rating FAST! If you’ve filed your VA disability claim and have been denied or have received a low rating—or you’re unsure how to get started—reach out to us! Take advantage of a FREE VA Claim Discovery Call. Learn what you’ve been missing—so you can FINALLY get the disability rating and compensation YOU DESERVE!

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