Print Va Form 21 4192 PDF Details

Did you know that you can print Va Form 21 4192 from your home computer? This form is used to apply for a Certificate of Eligibility (COE) for home loan benefits. The COE proves to your lender that you are eligible for a VA-backed loan. In order to print the form, you will need to have Adobe Reader installed on your computer. Once you have the software installed, open the PDF file and click on the "Print" button. You can then fill out the form and submit it to your lender. If you have any questions about the application process, be sure to contact your lender or VA representative.

You'll discover info about the type of form you intend to fill out in the table. It will tell you how much time it may need to finish print va form 21 4192, exactly what parts you need to fill in, etc.

QuestionAnswer
Form NamePrint Va Form 21 4192
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
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OMB Control No. 2900-0065

Respondent Burden: 15 minutes

Expiration Date: 7/31/2024

VA DATE STAMP

DO NOT WRITE IN THIS SPACE

REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR

DISABILITY BENEFITS

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 address below. Please be sure to sign and date this form in Items 23A and 23B. 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.

Where to Send Correspondence - After completing the form, mail to:

Department of Veterans Affairs

Evidence Intake Center

P.O. Box 4444

Janesville, WI 53547-4444

SECTION I - IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and completely fill in each applicable circle to help expedite processing of the form.

3. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)

4. SOCIAL SECURITY NUMBER

5. VA FILE NUMBER (If applicable)

6. DATE OF BIRTH

Month

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II - EMPLOYMENT INFORMATION (To be completed by employer)

7. BEGINNING DATE OF EMPLOYMENT

8. ENDING DATE OF EMPLOYMENT

 

 

 

 

 

9. TYPE OF WORK PERFORMED

 

Month

 

 

 

Day

 

 

 

 

Year

 

Month

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. AMOUNT EARNED DURING 12 MONTHS PRECEDING

 

LAST DATE OF

 

11. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT

 

EMPLOYMENT (BEFORE DEDUCTIONS)

 

 

 

 

 

 

 

 

 

(DUE TO DISABILITY)

$

 

 

 

 

 

 

,

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12A. NUMBER OF HOURS WORKED (Daily)

 

 

 

 

 

 

 

12B. NUMBER OF HOURS WORKED (Weekly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. CONCESSIONS (if any) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY

 

14A. IF VETERAN IS NOT WORKING, STATE THE REASON FOR TERMINATION OF EMPLOYMENT:

 

14B. DATE LAST WORKED

 

 

 

 

 

 

 

 

 

 

(IF RETIRED ON DISABILITY, PLEASE SPECIFY)

 

 

 

Month

Day

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15A. DATE OF LAST PAYMENT

 

 

 

 

 

15B. GROSS AMOUNT

16A. WAS LUMP SUM

16B. DATE PAID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF LAST PAYMENT

PAYMENT MADE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

Day

 

Year

 

YES

NO

 

Month

Day

 

 

 

 

Year

 

 

 

 

 

GROSS AMOUNT PAID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS (Only complete if claimant is currently serving in the Reserve or National Guard)

17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?

17B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES?

YES

NO

 

 

 

 

 

 

VA FORM

21-4192

SUPERSEDES VA FORM 21-4192, SEP 2017.

Page 1

JUL 2021

 

 

VETERAN'S SOCIAL SECURITY NO.

 

SECTION IV - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS (To be completed by employer)

18. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE, AS A RESULT OF HIS/HER EMPLOYMENT WITH YOU, SICK, RETIREMENT OR OTHER BENEFITS?

YES

NO (If "Yes," complete Items 19 through 21C)

19.TYPE OF BENEFIT

20.GROSS MONTHLY AMOUNT OF BENEFIT

$

,

.

21A. DATE BENEFIT BEGAN

21B. DATE FIRST PAYMENT ISSUED

21C. DATE BENEFIT WILL STOP (If known)

Month

Day

Year

Month

Day

Year

Month

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. REMARKS

I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief.

23A. SIGNATURE OF EMPLOYER OR SUPERVISOR (Required)

23B. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a meterial fact, knowing it to be false, or for fraudulent acceptance of any payment to which you are not entitled.

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. Your obligation to respond is voluntary. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U. S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine eligibility for disability benefits based on unemployability (38 U.S.C. 1521). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.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 2021

Page 2

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