OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)

OMB 2900-0065 · VA.

OMB 2900-0065

VA Form 21-4192 is used to gather necessary employment information from veterans’ employers so VA can determine eligibility to increased disability benefits based on unemployability. Without this information, determination of entitlement would not be possible.

The latest form for Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) expires 2027-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form
Supplementary Document
Supplementary Document
Supporting Statement A
All Historical Document Collections
Approved without change
 Revision of a currently approved collection 2024-07-08
Approved without change
 Reinstatement with change of a previously approved collection 2021-05-20
Approved with change
 Extension without change of a currently approved collection 2017-06-08
Approved without change
 Revision of a currently approved collection 2014-09-02
Approved without change
 Extension without change of a currently approved collection 2013-09-20
Approved without change
 Extension without change of a currently approved collection 2010-12-23
Approved without change
 Extension without change of a currently approved collection 2007-11-14
Approved without change
 Extension without change of a currently approved collection 2004-08-19
Approved without change
 Extension without change of a currently approved collection 2001-07-13
Approved without change
 Reinstatement without change of a previously approved collection 1998-08-19
Withdrawn and continue
 Extension without change of a currently approved collection 1995-08-28
Approved without change
 Revision of a currently approved collection 1993-05-19
Approved without change
 Extension without change of a currently approved collection 1990-07-13
Approved with change
 No material or nonsubstantive change to a currently approved collection 1989-04-04
Approved without change
 Revision of a currently approved collection 1987-06-16
Approved with change
 No material or nonsubstantive change to a currently approved collection 1986-08-08
Approved without change
 Reinstatement with change of a previously approved collection 1984-08-06
Approved with change
 No material or nonsubstantive change to a currently approved collection 1981-07-17
Approved without change
 Revision of a currently approved collection 1980-06-06
Withdrawn and continue
 Revision of a currently approved collection 1980-03-04
Approved without change
 Revision of a currently approved collection 1976-10-07