Va Form 21 4140 1 PDF Details

The VA Form 21-4140-1, otherwise known as the Employment Questionnaire, serves a crucial role for veterans receiving compensation at the 100 percent rate due to being unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. This form, which must be submitted annually, aids the Department of Veterans Affairs (VA) in determining a veteran's continued eligibility for such compensation. It inquires about any employment over the past 12 months, requesting details on whether the veteran was employed, self-employed, or did not work at all during this period. The Privacy Act of 1974 safeguards the confidentiality of the information provided, which is used strictly for verifying continued eligibility for benefits. Veterans are required to certify their employment status accurately, whether they have engaged in any work or remained unemployed due to their disabilities, ensuring the VA can provide the maximum benefits under the law. The significance of timely submission cannot be overstated, as failing to return the form within 60 days may result in a reduction of benefits, emphasizing the form's critical role in maintaining a veteran’s compensation. Moreover, the form makes it clear that penalties for false statements can be severe, underscoring the importance of honesty in this process. This straightforward, yet significant document, reinforces the VA's commitment to supporting veterans by continuously assessing and meeting their needs.

QuestionAnswer
Form NameVa Form 21 4140 1
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesva forms 21 4140, va form 21 4140, 21 4140, form va 21 4140

Form Preview Example

 

 

 

 

 

 

 

OMB Approved No. 2900-0079

 

 

 

 

 

 

 

Respondent Burden: 5 minutes

 

EMPLOYMENT QUESTIONNAIRE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. DATE MAILED

 

 

 

STATION

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. FILE NUMBER

 

 

 

NAME

 

 

 

 

 

 

 

3. WERE YOU EMPLOYED BY VA, OTHERS OR

 

 

AND

 

 

SELF-EMPLOYED AT ANY TIME DURING THE

 

 

 

 

 

ADDRESS

PAST 12 MONTHS? (If "Yes," complete Section I

 

 

 

only, if "No," complete Section II only)

 

 

 

 

 

 

OF

 

 

 

 

 

 

 

VETERAN

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 required to obtain or retain benefits. 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 continued eligibility to compensation at the 100 percent rate based on individual unemployability (38 CFR 4.16). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 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.

INSTRUCTIONS

You are receiving compensation at the 100 percent rate based on being unable to secure or follow a substantially gainful occupation as a result of your service-connected disabilities. If you were self-employed or employed by others, including the Department of Veterans Affairs, at any time during the past 12 months, compete Section I of this form. If you have not been employed during the past 12 months, complete Section II of this form.

You must complete the required items fully and accurately and return the form to the VA office shown above within 60 days. If you do not return the form within 60 days, your benefits may be reduced.

SECTION I - EMPLOYMENT CERTIFICATION (List all employment for the past twelve months)

4A. NAME AND ADDRESS OF EMPLOYER

(If self-employed, write "self")

4B. TYPE OF WORK

4C. HOURS PER WEEK

4D. DATES OF EMPLOYMENT

OR SELF-EMPLOYMENT

FROM

TO

 

 

4E. TIME

LOST FROM

ILLNESS

4F. HIGHEST

GROSS

EARNINGS

PER MONTH

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

I UNDERSTAND THAT my continued entitlement to VA unemployability compensation benefits will be based on information that I have furnished on this form or that I hereafter may be required to furnish VA.

5A. DATE SIGNED

5B. SIGNATURE OF VETERAN

5C. ADDRESS (If different than above)

5D. TELEPHONE NUMBER(S) (Include Area Code)

A. DAYTIME

B. EVENING

 

 

SECTION II - UNEMPLOYMENT CERTIFICATION (Complete this section if you did NOT work during the past 12 months)

I CERTIFY THAT I have not been employed by VA, others or self-employed during the past twelve months.

I FURTHER CERTIFY THAT the items completed on this form are true and correct to the best of my knowledge and belief. I believe that my service-connected disability(ies) has not improved and continues to prevent me from securing or following gainful employment.

6A. DATE SIGNED

6B. SIGNATURE OF VETERAN

6C. ADDRESS (If different than above)

6D. TELEPHONE NUMBER(S) (Include Area Code)

A. DAYTIME

B. EVENING

 

 

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

VA FORM

21-4140-1

EXISTING STOCKS OF VA FORM 21-4140-1, JAN 2005,

AUG 2011

WILL BE USED.

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Part no. 1 of completing va form 21 4140

2. Once your current task is complete, take the next step – fill out all of these fields - If selfemployed write self, B TYPE OF WORK, C HOURS PER WEEK, FROM, ILLNESS, EARNINGS PER MONTH, I CERTIFY THAT the statements made, I UNDERSTAND THAT my continued, A DATE SIGNED B SIGNATURE OF, C ADDRESS If different than above, D TELEPHONE NUMBERS Include Area, A DAYTIME, B EVENING, SECTION II UNEMPLOYMENT, and I CERTIFY THAT I have not been with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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