Please rate Print Va Form 21 4192 Aug 2024
Section IV, Information on Benefit Entitlement and/or Payments, is also to be completed by employer.
Section III: only complete if claimant is currently serving in the Reserve or National Guard.
Sign: please be sure to sign and date this form in Items 23A and 23B.
Completing: you may complete the form online or by hand; if completed by hand, print the information requested in ink, neatly and legibly.
Help: for free help in completing this form, call VA toll-free at 1-800-827-1000.
| Question | Answer |
|---|---|
| Form Name | VA Form 21-4192 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 64 |
| Avg. time to fill out | 11 min |
| Edition | AUG 2024 |
| Where to send | Department of Veterans Affairs Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | 21-4192, VA 21-4192, VA Form 21-4192, VA Form 4192, Request for Employment Information in Connection with Claim for Disability Benefits |
| Official source | VA Form 21-4192 (Rev AUG 2024), Department of Veterans Affairs |
Print Va Form 21 4192 isn’t the one you’re looking for?
Please rate Print Va Form 21 4192 Aug 2024
