VA Form 21-4192 (Request for Employment Information in Connection with Claim for Disability Benefits) is the employer-side companion to a TDIU claim. It asks a former employer to confirm your dates of employment, earnings, the type of work, and why your employment ended.
How it fits a TDIU claim
TDIU (Total Disability based on Individual Unemployability) pays at the 100% rate when service-connected conditions prevent substantially gainful employment. To support that, the VA wants the employer's account of your work history — which is what 21-4192 collects.
Who completes it
The employer fills it out. You (or the VA) provide it to your former employers, who verify:
- •Dates you worked.
- •Earnings during that time.
- •The reason employment ended — especially whether your disability played a role.
Why it strengthens the claim
An employer confirming that you left or lost work because of your condition is powerful, independent evidence that backs up your own TDIU application (VA Form 21-8940).
Tip
Line up your former employers' current contact info before you file TDIU — chasing down old employers is a common source of delay.
VA forms mentioned in this guide
Put this to work
See what the 100% rate pays — the rate TDIU pays at — and where your current combined rating stands.
Rating CalculatorWant free, personalized help?
A VA-accredited Veterans Service Officer (VSO) helps with your claim at no cost — filing, evidence review, and appeals. Find an accredited representative on VA.gov →
This guide is educational information about the VA claims system — it is not legal or medical advice, and it does not predict or promise any claim outcome. Regulations and procedures change; always verify current requirements at VA.gov. VA Claim Commander is a self-service documentation tool, not a VSO, law firm, or VA-accredited representative.