Va Form 21-8940 - Veteran'S Application For Increased Compensation Based On Unemployability

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OMB 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 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 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. SOCIAL SECURITY NUMBER
3. DATE OF BIRTH
4. EMAIL ADDRESS (If applicable)
5. NAME OF VETERAN (First, Middle, Last) (Type or Print)
6. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
SECTION I - DISABILITY AND MEDICAL TREATMENT
9. DATE(S) OF TREATMENT BY DOCTOR(S)
7. WHAT SERVICE-CONNECTED DISABILITY
8. HAVE YOU BEEN UNDER A DOCTOR'S CARE
PREVENTS YOU FROM SECURING OR FOLLOWING
AND/OR HOSPITALIZED WITHIN THE PAST
ANY SUBSTANTIALLY GAINFUL OCCUPATION?
12 MONTHS?
12. DATE(S) OF HOSPITALIZATION
10. NAME AND ADDRESS OF DOCTOR(S)
11. NAME AND ADDRESS OF HOSPITAL
SECTION II - EMPLOYMENT STATEMENT
13. DATE YOUR DISABILITY AFFECTED FULL-TIME
14. DATE YOU LAST WORKED FULL-TIME
15. DATE YOU BECAME TOO DISABLED TO WORK
EMPLOYMENT
16A. WHAT IS THE MOST YOU EVER EARNED IN
16B. WHAT YEAR?
16C. OCCUPATION DURING THAT YEAR
ONE YEAR?
$
17. LIST ALL YOUR EMPLOYMENT INCLUDING SELF-EMPLOYMENT FOR THE LAST FIVE YEARS YOU WORKED
D. DATES OF EMPLOYMENT
F. HIGHEST GROSS
E. TIME LOST
B. TYPE OF
C. HOURS
A. NAME AND ADDRESS OF EMPLOYER
EARNINGS
FROM ILLNESS
WORK
PER WEEK
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
$
$
18. DID YOU LEAVE YOUR LAST JOB/SELF-EMPLOYMENT
19. DO YOU RECEIVE/EXPECT TO RECEIVE
20. DO YOU RECEIVE/EXPECT TO RECEIVE
BECAUSE OF YOUR DISABILITY?
DISABILITY RETIREMENT BENEFITS?
WORKERS COMPENSATION BENEFITS?
(If "Yes," give the facts in Item 25)
YES
NO
YES
NO
YES
NO
21. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?
(If "Yes," complete Items A, B, and C)
YES
NO
A. NAME AND ADDRESS OF EMPLOYER
B. TYPE OF WORK
C. DATE APPLIED
21-8940
VA FORM
SUPERSEDES VA FORM 21-8940, OCT 2004,
JUN 2011
WHICH WILL NOT BE USED

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