21-8940 Veteran S Application For Increased Compensation Based On Unemployability
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3OMB Approved No. 2900-0404
Respondent Burden: 45 minutes
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 service-
connected disability(ies) which has/have prevented you from securing or following any substantially gainful occupation. Answer all questions fully and accurately.
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
1. VA FILE NUMBER
2. VETERAN’S SOCIAL SECURITY NUMBER
3. DATE OF BIRTH
4. NAME OF VETERAN (First, Middle, Last) (Type or Print)
5. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
SECTION I - DISABILITY AND MEDICAL TREATMENT
6. WHAT SERVICE-CONNECTED DISABILITY PREVENTS YOU
7. HAVE YOU BEEN UNDER A DOCTOR’S CARE
8. DATE(S) OF TREATMENT BY DOCTOR(S)
FROM SECURING OR FOLLOWING ANY SUBSTANTIALLY
AND/OR HOSPITALIZED WITHIN THE PAST
GAINFUL OCCUPATION?
12 MONTHS?
9. NAME AND ADDRESS OF DOCTOR(S)
10. NAME AND ADDRESS OF HOSPITAL
11. DATE(S) OF HOSPITALIZATION
SECTION II - EMPLOYMENT STATEMENT
12. DATE YOUR DISABILITY AFFECTED FULL-TIME
13. DATE YOU LAST WORKED FULL-TIME
14. DATE YOU BECAME TOO DISABLED TO WORK
EMPLOYMENT
15A. WHAT IS THE MOST YOU EVER EARNED IN
15B. WHAT YEAR?
15C. OCCUPATION DURING THAT YEAR
ONE YEAR?
$
16. LIST ALL YOUR EMPLOYMENT INCLUDING SELF-EMPLOYMENT FOR THE LAST FIVE YEARS YOU WORKED
F. HIGHEST GROSS
D. DATES OF EMPLOYMENT
B. TYPE OF
C. HOURS
E. TIME LOST
A. NAME AND ADDRESS OF EMPLOYER
EARNINGS
WORK
PER WEEK
FROM ILLNESS
FROM
TO
PER MONTH
G. INDICATE YOUR TOTAL EARNED INCOME FOR THE PAST 12 MONTHS
H. IF PRESENTLY EMPLOYED, INDICATE YOUR CURRENT MONTHLY EARNED
INCOME
$
$
17. DID YOU LEAVE YOUR LAST JOB/SELF-EMPLOYMENT
18. DO YOU RECEIVE/EXPECT TO RECEIVE
19. DO YOU RECEIVE/EXPECT TO RECEIVE
BECAUSE OF YOUR DISABILITY?
DISABILITY RETIREMENT BENEFITS?
WORKERS COMPENSATION BENEFITS?
YES
NO
(If "Yes," give the facts in Item 24)
YES
NO
YES
NO
20. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?
YES
NO
(If "Yes," complete Items A, B, and C)
A. NAME AND ADDRESS OF EMPLOYER
B. TYPE OF WORK
C. DATE APPLIED
VA FORM
SUPERSEDES VA FORM 21-8940, MAR 2000,
21-8940
OCT 2004
WHICH WILL NOT BE USED.
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