Official VA Form

VA Form 21-4192

Request for Employment Information in Connection with Claim for Disability Benefits

VA Form 21-4192 — Request for Employment Information in Connection with Claim for Disability Benefits is an official U.S. Department of Veterans Affairs form used for disability. The current version was last revised 2021-07-06. It is 2 pages long. Download the up-to-date PDF below — BaseNeed syncs form data directly from VA.gov so you always get the current edition.

Download the official PDF (VA.gov) →

Last revised: 2021-07-06
First issued: 2022-06-06
Pages: 2
Administered by: VBA

Disability

Frequently asked questions

What is VA Form 21-4192 used for?

Request for Employment Information in Connection with Claim for Disability Benefits. It is an official VA form in the Disability category, administered by VBA.

Where can I download the current VA Form 21-4192?

Download the official PDF from VA.gov here: https://www.vba.va.gov/pubs/forms/VBA-21-4192-ARE.pdf (last revised 2021-07-06).

How long is VA Form 21-4192?

VA Form 21-4192 is 2 pages long, last revised 2021-07-06.

Always the current version — synced from VA.gov. BaseNeed is not affiliated with the U.S. Department of Veterans Affairs.

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More Disability forms

VA Form 21-4142a — General Release for Medical Provider Information to the Department of Veterans Affairs
VA Form 21P-0969 — Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC)
VA Form 21-0538 — Mandatory Verification of Dependents
VA Form 21-0845 — Authorization to Disclose Personal Information to a Third Party
VA Form VA9 — Appeal to Board of Veterans' Appeals
VA Form 21-4142 — Authorization to Disclose Information to the Department of Veterans Affairs (VA)
VA Form 21P-8416 — Medical Expense Report
VA Form 21-0781 — Statement in Support of Claim for Service Connection for PTSD

Nearby form numbers

VA Form 21-4142 — Authorization to Disclose Information to the Department of Veterans Affairs (VA)
VA Form 21-4142a — General Release for Medical Provider Information to the Department of Veterans Affairs
VA Form 21-4170 — Statement of Marital Relationship
VA Form 21-4193 — Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution
VA Form 21-4502 — Application for Automobile or Other Conveyance and Adaptive Equipment (UNDER 38 U.S.C. 3901-3904)
VA Form 21-526EZ — Application for Disability Compensation and Related Compensation Benefits