VA Form 21-8940

Step 1 of 4

			VA DATE STAMP (DO NOT WRITE IN THIS SPACE)
VETERAN'S APPLICATION FOR INCREASED COMPENSATION BASED ON UNEMPLOYABILITY
IMPORTANT: 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. See mailing information on page 4 of this form.
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 at https://secure.ssa.gov/ICON/main.jsp or call 1-800-772-1213 (Hearing Impaired TDD line 1-800-325-0778). You may also contact SSA by Internet at http://www.ssa.gov/ .

SECTION I - VETERAN IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly, insert one letter per box, and completely fill each applicable checkbox to help expedite processing of the form.

1. VETERAN'S NAME (First, Middle Initial, Last)

1. First Name

1. Middle Initial

1. Last Name

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

5. MAILING ADDRESS (No. and street or rural route, city or P.O., State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code

Postal Code

6. EMAIL ADDRESS (If applicable)

I agree to receive electronic correspondence from VA in regards to my claim.

7. TELEPHONE NUMBER (Include Area Code)

International Phone Number

Enter International Phone Number (If applicable)

SECTION II - DISABILITY AND MEDICAL TREATMENT

8. WHAT SERVICE-CONNECTED DISABILITY(IES) PREVENT(S) YOU FROM SECURING OR FOLLOWING ANY SUBSTANTIALLY GAINFUL OCCUPATION?

9. HAVE YOU BEEN UNDER A DOCTOR'S CARE AND/OR HOSPITALIZED WITHIN THE PAST 12 MONTHS?

YES

10. DATE(S) OF TREATMENT BY DOCTOR(S) (Go to Item 26 - Remarks - for additional dates)

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

11. NAME AND ADDRESS OF DOCTOR(S)

12. NAME AND ADDRESS OF HOSPITAL

13. DATE(S) OF HOSPITALIZATION (Go to Item 26 - Remarks - for additional dates)

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

SECTION III - EMPLOYMENT STATEMENT

14. DATE YOUR DISABILITY AFFECTED FULL-TIME EMPLOYMENT (MM/DD/YYYY)

15. DATE YOU LAST WORKED FULL-TIME (MM/DD/YYYY)

16. DATE YOU BECAME TOO DISABLED TO WORK (MM/DD/YYYY)

17A. WHAT IS THE MOST YOU EVER EARNED IN ONE YEAR?

17B. WHAT YEAR?

17C. OCCUPATION DURING THAT YEAR?

SECTION III - EMPLOYMENT STATEMENT (Continued)

18. LIST ALL YOUR EMPLOYMENT INCLUDING SELF-EMPLOYMENT FOR THE LAST FIVE YEARS YOU WORKED
(Include any military duty including inactive duty for training) (Note: For additional employment information use Section V, Remarks)

1. NAME AND ADDRESS OF EMPLOYER (OR UNIT)

TYPE OF WORK

HOURS PER WEEK

DATES OF EMPLOYMENT

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST FROM ILLNESS

HIGHEST GROSS EARNINGS PER MONTH

2. NAME AND ADDRESS OF EMPLOYER (OR UNIT)

TYPE OF WORK

HOURS PER WEEK

DATES OF EMPLOYMENT

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST FROM ILLNESS

HIGHEST GROSS EARNINGS PER MONTH

3. NAME AND ADDRESS OF EMPLOYER (OR UNIT)

TYPE OF WORK

HOURS PER WEEK

DATES OF EMPLOYMENT

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST FROM ILLNESS

HIGHEST GROSS EARNINGS PER MONTH

4. NAME AND ADDRESS OF EMPLOYER (OR UNIT)

TYPE OF WORK

HOURS PER WEEK

DATES OF EMPLOYMENT

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST FROM ILLNESS

HIGHEST GROSS EARNINGS PER MONTH

5. NAME AND ADDRESS OF EMPLOYER (OR UNIT)

TYPE OF WORK

HOURS PER WEEK

DATES OF EMPLOYMENT

FROM (MM/DD/YYYY)

TO (MM/DD/YYYY)

TIME LOST FROM ILLNESS

HIGHEST GROSS EARNINGS PER MONTH

SECTION V - REMARKS

NOTE: This section can be used for any additional information, if needed.

26. REMARKS

SECTION VI - AUTHORIZATION, CERTIFICATION, AND SIGNATURE

AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the person or entity, including but not limited to any organization, service provider, employer, or Government agency, to give the Department of Veterans Affairs any information about me except protected health information, and I waive any privilege which makes the information confidential.

CERTIFICATION OF STATEMENTS: I CERTIFY THAT as a result of my service-connected disabilities, I am unable to secure or follow any substantially gainful occupation and that the statements in this application are true and complete to the best of my knowledge and belief. I understand that these statements will be considered in determining my eligibility for VA benefits based on unemployability because of service-connected disability.

I UNDERSTAND THAT IF I AM GRANTED SERVICE-CONNECTED TOTAL DISABILITY BENEFITS BASED ON MY UNEMPLOYABILITY, I MUST IMMEDIATELY INFORM VA IF I RETURN TO WORK. I ALSO UNDERSTAND THAT TOTAL DISABILITY BENEFITS PAID TO ME AFTER I BEGIN WORK MAY BE CONSIDERED AN OVERPAYMENT REQUIRING REPAYMENT TO VA.

27. SIGNATURE OF CLAIMANT (Required)

28. DATE SIGNED (MM/DD/YYYY)

WITNESSES NEEDED IF "X" MARK IS MADE (Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known and the signature and address of such witnesses must be shown in Items 29A & 29B and 30A & 30B.

29A. SIGNATURE OF WITNESS (Sign in ink)

29B. ADDRESS OF WITNESS

30A. SIGNATURE OF WITNESS (Sign in ink)

30B. ADDRESS OF WITNESS

PENALTY: The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact, knowing it to be false or for the fraudulent acceptance of any payment to which you are not entitled.

SECTION VII - WHERE TO SEND CORRESPONDENCE

MAIL TO:

Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your response is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38, U.S.C. 5101(c)(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits provided under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control Number. The OMB control number for this project is 2900-0404, and it expires 07/31/2027. Public reporting burden for this collection of information is estimated to average 45 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0404 in any correspondence. Do not send your completed VA Form 21-8940 to this email address.

VETERAN'S APPLICATION FOR INCREASED COMPENSATION BASED ON UNEMPLOYABILITY

VETERAN'S APPLICATION FOR INCREASED
COMPENSATION BASED ON UNEMPLOYABILITY