Disability compensationVA Form 21-4192
Request for Employment Information in Connection with Claim for Disability Benefits
Asks a current or former employer to confirm your work history and earnings for a claim based on unemployability (TDIU). The employer fills out and returns it, not you.
You fill in only the identification block: your name, Social Security number, VA file number, date of birth, and the employer this request goes to. The employer completes the employment sections, then signs the form and mails it to the VA Evidence Intake Center in Janesville, Wisconsin (the mailing address is printed on the form). During a TDIU claim VA mails this form to each employer you listed; you can also print your prepared copy and hand it to a former employer who is willing to fill it out.
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Our on-site copy came from VA.gov on August 20, 2026. We check for updates monthly.
Have these ready
This form asks for:
- Your name and date of birth
- Your Social Security number, and your VA file number if you have one
- The employer's name and mailing address
BeneVets provides benefits navigation and education. For formal claims representation, connect with an accredited VSO representative.