Ask your former employer to complete this promptly — delays here slow your entire TDIU claim

If your employer is uncooperative, notify VA and provide whatever employment documentation you have

The employer's description of your limitations and accommodations is powerful evidence for TDIU

Veterans Affairsmoderate

Request for Employment Information

VA 21-4192 · VA

Sent to the veteran's last employer to verify employment history in connection with a disability benefits claim.

Form Details

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Where to Submit This Form

📬

Mail to VA Evidence Intake Center

Department of Veterans Affairs Evidence Intake Center PO Box 4444 Janesville, WI 53547-4444

📠

Fax to VA

Fax: 844-531-7818

Required Attachments

📎 Must be completed by the veteran's former employer
📎 Employment dates, job duties, and reason for leaving
📎 Any concessions or accommodations made for the veteran's disability

Processing Time

Processed as part of TDIU (VA 21-8940) claim — 3-6 months total.

What Happens Next

VA will use this employer statement to evaluate your TDIU claim. If the employer does not respond, VA may send follow-up requests.

Tips for This Form

✓ Ask your former employer to complete this promptly — delays here slow your entire TDIU claim
✓ If your employer is uncooperative, notify VA and provide whatever employment documentation you have
✓ The employer's description of your limitations and accommodations is powerful evidence for TDIU

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VA 10-10EZ · VA

Application for VA health benefits. Requires military service history, current insurance, income/assets, and toxic exposure history.

VA Health Benefits Update

VA 10-10EZR · VA

Health Benefits Update Form for veterans already enrolled in VA health care who need to update personal, insurance, financial, or military service information.

VA Disability Compensation Application

VA 21-526EZ · VA

Application for disability compensation and related benefits for service-connected conditions. Requires linking conditions to military service.

Intent to File a Claim

VA 21-0966 · VA

Preserves the effective date for a VA benefits claim while gathering evidence. Provides 1 year to submit the formal claim.

Authorization to Release Information to VA

VA 21-4142 · VA

Authorization and consent allowing VA to obtain private medical records from non-VA providers for disability claim adjudication.

General Release for Medical Provider Information

VA 21-4142a · VA

Companion form to 21-4142 allowing specific medical professionals to release records to VA for claim processing.

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