Va Form 21 8940 PDF Details

The VA Form 21-8940, titled "Veteran's Application for Increased Compensation Based on Unemployability," serves as a critical tool for veterans seeking to establish their eligibility for higher benefits due to service-connected disabilities that inhibit their ability to secure or follow substantially gainful employment. This document meticulously gathers information regarding the veteran's personal identification, medical history, employment details, and educational background, aiming to paint a comprehensive picture of the individual's current situation and limitations. With sections dedicated to outlining the veteran's service-connected disabilities, recent treatments, employment history—including any attempts to find work despite their disabilities—and educational training before and after becoming substantially unemployable, the form encapsulates a broad spectrum of data necessary for evaluating a claim for increased compensation. The explicit instructions emphasize the importance of providing accurate and thorough responses, given that the information submitted will heavily influence the determination of eligibility for benefits. Alongside the procedural aspects, the form also addresses potential overlaps with Social Security benefits and includes directives for authorization and certification of the information provided, underscoring the legal and ethical responsibilities of the claimant. A designated section for remarks offers applicants the opportunity to furnish additional details that could be pivotal to their application, ensuring that evaluators have access to all pertinent information. Furthermore, it underscores the legal implications of submitting false statements, reflecting the seriousness with which these claims are treated and the rigorous verification processes in place. By completing VA Form 21-8940, veterans take a significant step toward receiving the support and recognition they deserve, amidst acknowledging the potential for their circumstances to evolve, as indicated by the requirement to notify the VA of any return to employment, signifying a change in their unemployability status.

QuestionAnswer
Form NameVa Form 21 8940
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesva form 21 8940, unemployability claiming, how to file unemployability, how to unemployability

Form Preview Example

OMB Approved No. 2900-0404 Respondent Burden: 45 minutes Expiration Date: 06/30/2024

VETERAN'S APPLICATION FOR INCREASED

COMPENSATION BASED ON UNEMPLOYABILITY

IMPORTANT: This is a claim for compensation benefits based on unemployability. When you complete this form you are claiming total disability because of a service-connected disability(ies) which has/have prevented you from securing or following any substantially gainful occupation. Answer all questions fully and accurately. See mailing information on page 4 of this form.

Social Security Benefits: Individuals who have a disability and meet medical criteria may qualify for Social Security or Supplemental Security Income disability benefits. If you would like more information about Social Security benefits, contact your nearest Social Security Administration (SSA) office. You can locate the address of the nearest SSA office in your telephone book blue pages under "United States Government, Social Security Administration" or call 1-800-772-1213 (Hearing Impaired TDD line 1-800-325-0778). You may also contact SSA by Internet at http://www.ssa.gov/.

SECTION I - VETERAN IDENTIFICATION INFORMATION

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

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 each applicable circle to help expedite processing of the form.

1.VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH

Month

 

 

Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.MAILING ADDRESS (No. and street or rural route, city or P.O., State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province

Country

City

ZIP Code/Postal Code

6. EMAIL ADDRESS (If applicable)

I agree to receive electronic correspondence

from VA in regards to my claim.

7.TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

SECTION II - DISABILITY AND MEDICAL TREATMENT

8. WHAT SERVICE-CONNECTED DISABILITY PREVENTS

9. HAVE YOU BEEN UNDER A DOCTOR'S CARE

10. DATE(S) OF TREATMENT BY DOCTOR(S)

YOU FROM SECURING OR FOLLOWING ANY

AND/OR HOSPITALIZED WITHIN THE PAST 12

 

(Go to Item 26 - Remarks - for additional dates)

SUBSTANTIALLY GAINFUL OCCUPATION?

MONTHS?

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. NAME AND ADDRESS OF DOCTOR(S)

12. NAME AND ADDRESS OF HOSPITAL

13. DATE(S) OF HOSPITALIZATION

 

(Go to Item 26 - Remarks - for additional dates)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III - EMPLOYMENT STATEMENT

14.DATE YOUR DISABILITY AFFECTED FULL-TIME EMPLOYMENT

Month

 

 

Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. DATE YOU LAST WORKED FULL-TIME

16. DATE YOU BECAME TOO DISABLED TO WORK

Month

 

 

Day

 

 

 

Year

 

Month

 

 

Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17A. WHAT IS THE MOST YOU EVER EARNED IN ONE YEAR?

17B. WHAT YEAR?

17C. OCCUPATION DURING THAT YEAR?

$

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JUN 2021

21-8940

 

 

 

 

 

 

 

 

 

Page 1

VA FORM

 

 

 

 

 

 

SUPERSEDES VA FORM 21-8940, OCT 2017.

 

VETERAN'S SOCIAL SECURITY NUMBER

SECTION III - EMPLOYMENT STATEMENT (Continued)

18. LIST ALL YOUR EMPLOYMENT INCLUDING SELF-EMPLOYMENT FOR THE LAST FIVE YEARS YOU WORKED

(Include any military duty including inactive duty for training) (Note: For additional employment information use Section V, Remarks)

NAME AND ADDRESS OF EMPLOYER (OR UNIT)

TYPE OF WORK

HOURS

PER WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. DATES OF EMPLOYMENT

 

TIME LOST

HIGHEST GROSS EARNINGS

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

FROM ILLNESS

 

 

PER MONTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER (OR UNIT)

 

 

TYPE OF WORK

 

 

 

HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PER WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATES OF EMPLOYMENT

 

TIME LOST

 

 

HIGHEST GROSS EARNINGS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

FROM ILLNESS

 

 

 

 

PER MONTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER (OR UNIT)

 

 

TYPE OF WORK

 

 

 

 

HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PER WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATES OF EMPLOYMENT

 

 

 

 

 

 

 

TIME LOST

HIGHEST GROSS EARNINGS

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

FROM ILLNESS

 

 

PER MONTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER (OR UNIT)

 

 

 

 

 

 

 

 

TYPE OF WORK

 

 

 

 

HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PER WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATES OF EMPLOYMENT

 

 

 

 

 

 

 

 

 

 

 

 

TIME LOST

 

FROM

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

FROM ILLNESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

HIGHEST GROSS EARNINGS

PER MONTH

,

NAME AND ADDRESS OF EMPLOYER (OR UNIT)

TYPE OF WORK

HOURS

PER WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

DATES OF EMPLOYMENT

 

 

 

 

 

 

 

TIME LOST

 

HIGHEST GROSS EARNINGS

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

FROM ILLNESS

 

 

PER MONTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 21-8940, JUN 2021

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2

VETERAN'S SOCIAL SECURITY NUMBER

SECTION III - EMPLOYMENT STATEMENT (Continued)

19.IF YOU ARE CURRENTLY SERVING IN THE RESERVE OR NATIONAL GUARD, DOES YOUR SERVICE CONNECTED DISABILITY PREVENT YOU FROM PERFORMING YOUR MILITARY DUTIES?

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20A. INDICATE YOUR TOTAL EARNED INCOME FOR THE PAST 12 MONTHS

 

20B. IF PRESENTLY EMPLOYED, INDICATE YOUR CURRENT MONTHLY EARNED

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

INCOME

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21A. DID YOU LEAVE YOUR LAST JOB/SELF-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21B. DO YOU RECEIVE/EXPECT TO RECEIVE

21C. DO YOU RECEIVE/EXPECT TO RECEIVE

 

 

EMPLOYMENT BECAUSE OF YOUR DISABILITY?

DISABILITY RETIREMENT BENEFITS?

 

 

WORKERS COMPENSATION BENEFITS?

 

 

YES

 

NO

 

(If "Yes," explain in Item 26,

YES

 

NO

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

 

 

 

 

"Remarks")

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO (If "Yes," complete Items 22A, 22B, and 22C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22A.

 

 

 

 

22B.

 

 

 

 

 

 

 

 

 

 

 

 

22C.

 

 

 

 

NAME AND ADDRESS OF EMPLOYER

 

 

 

TYPE OF WORK

 

 

 

 

DATE APPLIED (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER

TYPE OF WORK

 

DATE APPLIED (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER

TYPE OF WORK

 

DATE APPLIED (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION IV - SCHOOLING AND OTHER TRAINING

23.EDUCATION (Check highest year completed)

GRADE SCHOOL

1

2 3

4

5 6

7

8 HIGH SCHOOL

9

10

11 12 COLLEGE

Fresh

Soph

Jr

Sr

24A. DID YOU HAVE ANY OTHER EDUCATION AND TRAINING BEFORE YOU WERE TOO DISABLED TO WORK?

 

 

 

 

YES

 

NO

 

(If "Yes," complete Items 24B and 24C)

 

 

24B. TYPE OF EDUCATION OR TRAINING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24C. DATES OF TRAINING

 

BEGINNING (MM/DD/YYYY)

 

 

COMPLETION (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25A. HAVE YOU HAD ANY EDUCATION AND TRAINING SINCE YOU BECAME TOO DISABLED TO WORK?

YES

 

NO

 

(If "Yes," complete Items 25B and 25C)

 

 

25B. TYPE OF EDUCATION OR TRAINING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25C. DATES OF TRAINING

 

BEGINNING (MM/DD/YYYY)

 

 

COMPLETION (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 21-8940, JUN 2021

Page 3

VETERAN'S SOCIAL SECURITY NUMBER

SECTION V - REMARKS

NOTE: This section can be used for any additional information, if needed. 26. REMARKS

SECTION VI - AUTHORIZATION, CERTIFICATION, AND SIGNATURE

AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the person or entity, including but not limited to any organization, service provider, employer, or Government agency, to give the Department of Veterans Affairs any information about me except protected health information, and I waive any privilege which makes the information confidential.

CERTIFICATION OF STATEMENTS: I CERTIFY THAT as a result of my service-connected disabilities, I am unable to secure or follow any substantially gainful occupation and that the statements in this application are true and complete to the best of my knowledge and belief. I understand that these statements will be considered in determining my eligibility for VA benefits based on unemployability because of service-connected disability.

I UNDERSTAND THAT IF I AM GRANTED SERVICE-CONNECTED TOTAL DISABILITY BENEFITS BASED ON MY UNEMPLOYABILITY, I MUST IMMEDIATELY INFORM VA IF I RETURN TO WORK. I ALSO UNDERSTAND THAT TOTAL DISABILITY BENEFITS PAID TO ME AFTER I BEGIN WORK MAY BE CONSIDERED AN OVERPAYMENT REQUIRING REPAYMENT TO VA.

27. SIGNATURE OF CLAIMANT (Required)

28. DATE SIGNED (MM/DD/YYYY)

WITNESSES NEEDED IF "X" MARK IS MADE (Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known and the signature and address of such witnesses must be shown in Items 29A & 29B and 30A & 30B.

29A. SIGNATURE OF WITNESS (Sign in ink)

29B. ADDRESS OF WITNESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30A. SIGNATURE OF WITNESS (Sign in ink)

30B. ADDRESS OF WITNESS

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 the fraudulent acceptance of any payment to which you are not entitled.

SECTION VII - WHERE TO SEND CORRESPONDENCE

MAIL TO:

Department of Veterans Affairs

Evidence Intake Center

PO Box 4444

Janesville, WI 53547-4444

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 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 Veteran Readiness and Employment Records - VA, published in the Federal Register. Your response is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38, U.S.C. 5101 (c)(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits provided 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 your eligibility for compensation. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 45 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 21-8940, JUN 2021

Page 4

How to Edit Va Form 21 8940 Online for Free

This PDF editor makes it simple to manage the how to file unemployability file. You should be able to create the file effortlessly through these basic steps.

Step 1: First, select the orange button "Get Form Now".

Step 2: The form editing page is currently available. It's possible to add text or update present details.

The next segments are included in the PDF form you will be completing.

what is unemployability for va fields to fill in

Type in the required particulars in YES, NAME AND ADDRESS OF DOCTORS, NAME AND ADDRESS OF HOSPITAL, DATES OF HOSPITALIZATION Go to, FROM, DATE YOUR DISABILITY AFFECTED, DATE YOU LAST WORKED FULLTIME, DATE YOU BECAME TOO DISABLED TO, Month, Day, Year, Month, Day, Year, and Month segment.

Finishing what is unemployability for va stage 2

You could be asked for some valuable details to be able to fill up the VETERANS SOCIAL SECURITY NUMBER, LIST ALL YOUR EMPLOYMENT, SECTION III EMPLOYMENT STATEMENT, NAME AND ADDRESS OF EMPLOYER OR, TYPE OF WORK, HOURS PER WEEK, D DATES OF EMPLOYMENT, FROM, NAME AND ADDRESS OF EMPLOYER OR, TIME LOST FROM ILLNESS, HIGHEST GROSS EARNINGS PER MONTH, TYPE OF WORK, HOURS PER WEEK, DATES OF EMPLOYMENT, and TIME LOST FROM ILLNESS section.

part 3 to finishing what is unemployability for va

Within the field FROM, TIME LOST FROM ILLNESS, HIGHEST GROSS EARNINGS PER MONTH, NAME AND ADDRESS OF EMPLOYER OR, TYPE OF WORK, HOURS PER WEEK, DATES OF EMPLOYMENT, FROM, TIME LOST FROM ILLNESS, HIGHEST GROSS EARNINGS PER MONTH, NAME AND ADDRESS OF EMPLOYER OR, TYPE OF WORK, HOURS PER WEEK, DATES OF EMPLOYMENT, and FROM, identify the rights and responsibilities of the sides.

Filling in what is unemployability for va part 4

Complete the file by looking at these sections: NAME AND ADDRESS OF EMPLOYER OR, TYPE OF WORK, HOURS PER WEEK, DATES OF EMPLOYMENT, FROM, TIME LOST FROM ILLNESS, HIGHEST GROSS EARNINGS PER MONTH, VA FORM JUN, and Page.

what is unemployability for va NAME AND ADDRESS OF EMPLOYER OR, TYPE OF WORK, HOURS PER WEEK, DATES OF EMPLOYMENT, FROM, TIME LOST FROM ILLNESS, HIGHEST GROSS EARNINGS PER MONTH, VA FORM  JUN, and Page fields to insert

Step 3: Hit the "Done" button. Now you can upload your PDF form to your gadget. Additionally, you can deliver it through email.

Step 4: It may be simpler to have copies of the document. There is no doubt that we are not going to reveal or view your particulars.

Watch Va Form 21 8940 Video Instruction

Please rate Va Form 21 8940

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .