FORMS


Return to GetKansasBenefits.gov

Please send your completed forms to KDOL.UICC@ks.gov.

You may also send by mail or fax.

Unemployment Contact Center
P.O. Box 3539
Topeka, KS 66601-3539
FAX: (785) 296-3249


All required forms should be completed and returned to the Kansas Unemployment Contact Center as indicated on the form. Many of the forms can be completed online and submitted by using the "Submit" button at the bottom of the form. The light blue boxes indicate the fillable areas. Print a copy of the completed form for your records. If you submit the form via email or the “Submit” button, your statement will be considered signed when received. If faxing the form, be sure to print all the pages and send both sides of the form if you have written information on the back of the page. If you choose not to submit the form electronically, be sure to sign it before sending it to the Contact Center. 


Note: If you use the "Submit" button, it works only with the Internet Explorer browser.  The “Submit” button does not work with Chrome, Edge, and Firefox. 



Able and Available Statement: Medical Condition or Workers Compensation, K-BEN 31
Fill out this form if you have a medical condition or have accepted workers compensation benefits. This form will help indicate if you are able and available to work. Complete this form and return it within seven days of the date you filed your claim.

Alien Statement
If you have indicated that you are not a U.S. citizen, fill out this form to provide more information on your Alien status. Complete this form and return it within seven days of the date you filed your claim. Attach a copy of your alien card (front and back).

  • Delcaración de Extranjero. K-BEN 3117-A
    Si ha indicado que no es ciudadano estadounidense, complete este formulario para proporcionar más información sobre su estado de Extranjero. Complete este formulario y devuélvalo dentro de los siete días posteriores a la fecha en que presentó su reclamo. Adjunte una copia de su tarjeta de extranjero (anverso y reverso).

Availability Statement, K-BEN 32
You indicated you have limitations that may prevent you from accepting work or may limit your availability to work. This form will help KDOL better understand what your limitations are. Complete this form and return it within seven days of the date you filed your claim.

  • Declaración de Capacidad y Disponibilidad, K-BEN 32-SA
    Usted indicó que tiene limitaciones que pueden impedirle aceptar el trabajo o limitar su disponibilidad para trabajar. Este formulario ayudará a KDOL a comprender mejor cuáles son sus limitaciones. Complete este formulario y devuélvalo dentro de los siete días posteriores a la fecha en que presentó su reclamo.

Back Pay Award - Claimant
If you received a back pay award from your employer,  fill out this form to provide more information. Return this form by the due date listed on the mailed form to avoid a possible denial of payment.

  • Recompensa De Pago Atrasado – Reclamante, K-BEN 3111-S
    Si recibió un premio de pago atrasado de su empleador, complete este formulario para proporcionar más información. Devuelva este formulario antes de la fecha de vencimiento que figura en el formulario enviado por correo para evitar una posible denegación de pago.

Bonus Pay – Claimant K-BEN 3121
If you have indicated that you have or will receive bonus pay from your employer, fill out this form to provide more information. Complete this form and return it within seven days of the date you filed your claim.

Claimant Separation Statement, K-BEN 3110
Complete all fields on both sides and return the completed form at least 3 days before your scheduled call. This information will be used to determine whether you are entitled to unemployment benefits.

Do These Activities to Get Paid Benefits, K-BEN 992
Unemployed workers who do the following activities are far more likely to avoid interruption and receive timely payment of needed benefits.

Health Care Provider's Certification, K-BEN 312
You have determined you have a medical condition that may limit your ability to work. Health care information is required to determine if you are eligible for unemployment insurance benefits. Take this form to your health care provider for completion and then sign the certification. Return this form within seven days of the date you filed your claim. 

Income Tax Withholding Agreement, K-BEN 233
Unemployment benefits are taxable income under state and federal law. You have the option of having income taxes withheld from your weekly unemployment benefits. To do so, you must complete the Agreement to Withhold Taxes section in this document and return the form to the Unemployment Contact Center. To end a current withholding,  complete the Request to Cancel Withholdings section in this document and return the form to the Unemployment Contact Center.

  • Contrato De Retencion De Impuesto, K-BEN 233-S
    Los beneficios de desempleo son ingresos imponibles según la ley estatal y federal. Tiene la opción de que se le retengan los impuestos sobre la renta de sus beneficios semanales de desempleo. Para hacerlo, debe completar la sección Acuerdo para retener impuestos en este documento y devolver el formulario al Centro de contacto de desempleo. Para finalizar una retención actual, complete la sección Solicitud de cancelación de retenciones en este documento y devuelva el formulario al Centro de contacto de desempleo.

Job Refusal Statement, K-BEN 3118-A
If you have refused a job offer while receiving unemployment benefits, you are required to provide more information on the job and your reasoning for refusing it. Complete this form and return it within seven days of the date you filed your claim. 

Labor Dispute Statement, K-BEN 314
If you are a part of a labor dispute with your employer and are not working because of it, you will need to provide more information to determine if you are eligible for unemployment benefits. Complete and return this form within seven days of the date you filed your claim. 

My Reemployment Plan, K-BEN 990
This form is used to assist claimants in finding new employment through work searches and assessments. Fill out and return this form within seven days from your filing date.

  • Mi Plan de Reempleo, K-BEN 990-A
    Este formulario se utiliza para ayudar a los solicitantes a encontrar un nuevo empleo a través de búsquedas y evaluaciones laborales. Complete y devuelva este formulario dentro de los siete días a partir de su fecha de presentación.

Officer of Corporation Statement, K-BEN 3120-B
If you have indicated you are an officer for a corporation, you need to provide more information on your role and duties. Complete this form and return it within seven days of the date you filed your claim. 

Pension Statement, K-BEN 3113
The Kansas Employment Security Law requires that certain pensions and retirement benefits be deducted from unemployment insurance payments. Complete this form and return it within seven days of the date you filed your claim.

Reasonable Assurance Statement, K-BEN 3136
If you are or were a school employee, you are required to provide additional information on your employment history. Complete this form and return it within seven days of the date you filed your claim. 

Request for Disclosure of Tax/Benefit Information, K-RM 002
You have the right to request additional information regarding benefit or tax information. Fill out this form and return to KDOL.

Request for Information - Ability to Work, K-BEN 5691
Additional information is required to determine your eligibility for benefits. Complete and return this form within seven days of the date you filed your claim. 

School Attendance, K-BEN 317
You have indicated that you are currently attending or enrolled to attend school or training. In order to determine your eligibility for unemployment benefits, you must complete this form and return it within seven days of the date you filed your claim.


Self Employment Statement, K-BEN 3120-A
If you are self-employed, you are required to provide additional information regarding your self-employment. Complete this form and return it within seven days of the date you filed your claim.

Separation Pay Statement, K-BEN 3119
If you have or will receive separation, termination, severance or other similar pay, you are required to provide additional information to KDOL. Complete this form and return it within seven days of the date you filed your claim. 

Substitute School Employee Statement, K-BEN 3137
If you are or were a substitute school employee, you are required to provide additional information on your employment history. Complete this form and return it within seven days of the date you filed your claim. 

Warn Act Award – Claimant, K-BEN 3115
If you have received or receive WARN Act payment from an employer, you are required to provide additional information to KDOL. Complete this form and return it within seven days of the date you filed your claim. 

Worked Full-Time, K-BEN 230
You reported on your weekly claim for unemployment insurance benefits that you worked 40 or more hours during the week being claimed. Additional information is required to determine your eligibility to receive benefits for this week. Complete and return this form so that it is received within seven days of the date you filed your claim. 

Work Search Activity Log, K-BEN 987
You must perform three work search activities each week in order to maintain your eligibility for unemployment benefits. Two of those work search activities each week must be an application for employment or submission of a resume. Other activities could include additional job applications, attendance at job fairs, resume review courses, Workforce Center services, browsing job posting websites, etc. We recommend that you keep a written record of your work search activities. We may ask you to provide the details of your work search to ensure you are meeting all eligibility requirements.