You'll find information regarding the type of form you want to complete in the table. It will show you the time it takes to finish va form 21 8940, exactly what fields you will have to fill in and some other specific details.
Question | Answer |
---|---|
Form Name | Va Form 21 8940 |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | compensation unemployability, va unemployability, what is unemployability for va, application unemployability |
OMB Approved No.
VETERAN'S APPLICATION FOR INCREASED
COMPENSATION BASED ON UNEMPLOYABILITY
NOTE: This is a claim for compensation benefits based on unemployability. When you complete this form you are claiming total disability because of a
Social Security Benefits: Individuals who have a disability and meet medical criteria may qualify for Social Security of 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
SECTION I - VETERAN IDENTIFICATION INFORMATION
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)
NOTE: You can EITHER complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly to expedite processing the form.
1.NAME OF VETERAN (FIRST, MIDDLE INITIAL, LAST)
2. VETERAN'S SOCIAL SECURITY NUMBER |
|
|
3. VA FILE NUMBER |
|
|
|
|
|
4. DATE OF BIRTH (MM,DD,YYYY) |
|
|
|
||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Month |
|
|
Day |
Year |
|||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5.MAILING ADDRESS OF VETERAN (No. and street or rural route, city or P.O., State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province |
|
|
Country |
|
|
|
|
6.EMAIL ADDRESS (If applicable)
City
ZIP Code/Postal Code
7.TELEPHONE NUMBER (Include Area Code)
SECTION II - DISABILITY AND MEDICAL TREATMENT
8.WHAT
9.HAVE YOU BEEN UNDER A DOCTOR'S CARE AND/OR HOSPITALIZED WITHIN THE PAST 12 MONTHS?
|
YES |
|
NO |
10. DATE(S) OF TREATMENT BY DOCTOR(S)
FROM |
TO |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
11. NAME AND ADDRESS OF DOCTOR(S)
12. NAME AND ADDRESS OF HOSPITAL
13. DATE(S) OF HOSPITALIZATION
FROM |
TO |
|
|
SECTION III - EMPLOYMENT STATEMENT
14. DATE YOUR DISABILITY AFFECTED |
15. DATE YOU LAST WORKED |
||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
Month |
|
|
Day |
Year |
|
Month |
|
|
Day |
Year |
|||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
17A. WHAT IS THE MOST YOU EVER EARNED IN ONE YEAR? |
|
17B. WHAT YEAR? |
|
|
|
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Year |
|
|
|
$
16. DATE YOU BECAME TOO DISABLED TO WORK
Month |
|
|
Day |
|
|
|
Year |
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
17C. OCCUPATION DURING THAT YEAR
VA FORM |
SUPERSEDES VA FORM |
Page 1 |
|
OCT 2017 |
WHICH WILL NOT BE USED. |
VETERAN'S SOCIAL SECURITY NO.
SECTION III - EMPLOYMENT STATEMENT (CONTINUED)
18.LIST ALL YOUR EMPLOYMENT INCLUDING
A. NAME AND ADDRESS OF EMPLOYER
(OR UNIT)
B. TYPE OF |
C. HOURS |
WORK |
PER WEEK |
|
|
D. DATES OF EMPLOYMENT |
E. TIME LOST |
F. HIGHEST GROSS |
|
|
|
||
FROM |
TO |
FROM ILLNESS |
EARNINGS PER MONTH |
|
|
18G. 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 |
18H. INDICATE YOUR TOTAL EARNED INCOME FOR THE PAST 12 MONTHS
$
18I. IF PRESENTLY EMPLOYED, INDICATE YOUR CURRENT MONTHLY EARNED INCOME
$
19. DID YOU LEAVE YOUR LAST |
20. DO YOU RECEIVE/EXPECT TO RECEIVE |
BECAUSE OF YOUR DISABILITY? |
DISABILITY RETIREMENT BENEFITS? |
|
YES |
|
NO |
(If "Yes," give the facts in Item 26, |
|
YES |
|
NO |
|
|
|
|
|||||
|
|
"Remarks") |
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
21.DO YOU RECEIVE/EXPECT TO RECEIVE WORKERS COMPENSATION BENEFITS?
|
YES |
|
NO |
22. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?
|
YES |
|
NO |
(If "Yes," complete Items 22A, 22B, and 22C) |
|
|
|
|
A. NAME AND ADDRESS OF EMPLOYER |
B. TYPE OF WORK
C. DATE APPLIED
SECTION IV - SCHOOLING AND OTHER TRAINING
23.EDUCATION (Check highest year completed)
|
GRADE SCHOOL |
|
|
1 |
|
2 |
|
3 |
|
|
4 |
|
5 |
|
6 |
|
7 |
|
8 |
HIGH SCHOOL |
|
1 |
|
2 |
|
3 |
|
4 COLLEGE |
|
1 |
|
2 |
|
3 |
|
4 |
||||||
|
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 |
|
|
|
|
COMPLETION |
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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 |
COMPLETION |
|
|
VA FORM |
Page 2 |
VETERAN'S SOCIAL SECURITY NO.
26. REMARKS (If any)
SECTION IV - 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
I UNDERSTAND THAT IF I AM GRANTED
27.SIGNATURE OF CLAIMANT (Do Not Print) (Sign in ink)
28. DATE SIGNED
WITNESS TO SIGNATURE OF CLAIMANT IF MADE "X" MARK. NOTE: Signature made by mark must be witnessed by two persons to whom the person making the statement is personally know and the signature and address of such witnesses must be shown below.
29A. SIGNATURE OF WITNESS (Sign in ink)
29B. ADDRESS OF WITNESS
30A. SIGNATURE OF WITNESS (Sign in ink)
30B. ADDRESS OF WITNESS
SECTION V - WHERE TO SEND CORRESPONDENCE
MAIL TO:
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI
FAX TO:
Local:
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.
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 Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond 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
VA FORM |
Page 3 |