Va Form 21-4192 - Request For Employment Information In Connection With Claim For Disability Benefits

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OMB Control No. 2900-0065

Respondent Burden: 15 minutes

Expiration Date: 11/30/2017

REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS

SECTION I - IDENTIFICATION INFORMATION (To be completed by VA)

(Complete)

1. NAME AND ADDRESS OF EMPLOYER OF VETERAN

2. ADDRESS

RETURN

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 above address.

Please be sure to sign and date this form in Items 21A and 21B. 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.

3. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN

4. SOCIAL SECURITY NO.

5. VA FILE NO.

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

6. BEGINNING DATE OF EMPLOYMENT

7. ENDING DATE OF EMPLOYMENT

Month

Day

Year

Month

Day