The following information about this VA form comes from the VA forms database, and any changes are updated here nightly. Contact the form administration for further information.
Link to form
http://www.vba.va.gov/pubs/forms/VBA-21-4192-ARE.pdf
Form number
21-4192
Row ID
2429
Form title
Request for Employment Information in Connection With Claim for Disability Benefits (Fillable)
Issue date
Revision date
Form administration
VBA
Number of pages
2
Deleted
False
Form name
Request for Employment Information in Connection with Claim for Disability Benefits
Form Language
English
Related to
Benefits
VA disability compensation
When to use

Use VA Form 21-4192 if you’re a Veteran and you need your most recent employer to send us information so you can apply for Individual Unemployability disability benefits. Your most recent employer must complete and submit this form.

Related forms
About VA Form 21-8940
Helpful links
Eligibility for VA disability benefits
Find out if you qualify for compensation for a presumptive disability or other service-connected conditions.
How to file a VA disability claim
Find out how to file a claim for disability compensation or increased disability compensation.
File additional forms for your disability claim
Find out if you need to complete additional forms for your disability claim.
VA Individual Unemployability if you can't work
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.