Unemployment Forms

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All required forms need to be completed and returned to the Kansas Unemployment Contact Center as indicated on the form. Before submitting the form you must complete the fillable areas indicated in light blue boxes. Once completed we suggest saving a copy on your computer or print a copy for your records. When you're ready to submit the form(s) please select one of the options indicated on the form. Many of the forms will provide options such as mail, fax or upload to the portal.

Please be advised, if you choose:

Mail: sign the form(s) before sending to the Contact Center
Fax: print all the pages and send both sides of the form(s) if you have written information on the back of the page.
Portal: be sure to save the form(s) as a DOC, DOCX, XLS, XLSX, CSV, JPEG, JPG, PNG or PDF

Unsworn Declaration of Payments Not Received/Identity Theft (K-FRD 100)

If you have received a Determination letter, Notice of Overpayment letter, or 1099-G form for a claim that you did not receive payment for due to identity theft, fill out a request on the KDOL Self-Service Portal under Dispute my 1099, making sure to check the box for I want to dispute my 1099 and upload the completed form to declare you did not receive the benefits stated on the form issued from the Kansas Department of Labor.

NOTE: 1099-G Tax Forms are mailed out each year in January to claimants who received unemployment insurance benefits the previous year. To request a new 1099-G to be mailed to you, log into GetKansasBenefits.gov and click REQUEST 1099-G REPRINT.

Unsworn Declaration of Payments Not Received, Identity Theft (English)
Declaración sin Juramento de Pagos No Recibidos/Robo de Identidad (Español)

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.

Able and Available Statement: Medical Condition or Workers Compensation (English)
Declaración de Capacidad y Disponibilidad: Enermedad o Compensación a Los Trabajadores (Español)

Alien Employment Statement (K-BEN 3117-A)

Availability Statement (K-BEN 32)

Back Pay Award – Claimant (K-BEN 3111)

Bonus Pay – Claimant (K-BEN 3121)

Claimant Separation Statement (K-BEN 3110)

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.

Health Care Provider's Certification (English)
Certificación De Proveedor de Atención Médica (Español)

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.

Income Tax Withholding Agreement (English)
Contracto de Retencion de Impuestos (Español)

Job Refusal - Claimant (K-BEN 3118)

Labor Dispute Statement (K-BEN 314)

Pension Statement (K-BEN 3113)

Reasonable Assurance Statement (K-BEN 3136)

Request for Disclosure of Tax/Benefit Information (K-RM 002)

Request for Disclosure of Tax/Benefit Information - Media (K-RM 003)

Request for Information – Ability to Work (K-BEN 5691)

School Attendance (K-BEN 317)

Self Employment Statement (K-BEN 3120)

Separation Pay - Claimant (K-BEN 3123)

Substitute School Employee Statement (K-BEN 3137)

Warn Act – Claimant (K-BEN 3115)

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

Worked Full-Time (English)

Trabajó Tiemop Completo (Español)

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.

Work Search Activity Log (English)
Registro de Actividades de Búsqueda de Trabajo (Español)

Overpayment Waiver Request (K-CNS 2203)

If you receive an overpayment not due to confirmed fraud or ID theft, and repaying the overpayment would be against equity and good conscience or cause undue hardship, you may be eligible to have the overpayment waived and your debt forgiven. To request an overpayment waiver, you must fill out the UI Overpayment Waiver Request form (K-CNS 2203) completely, and include an explanation and documentation with your submission as the form states.

UI Overpayment Waiver Request (English)
Solicitub de Renuncia de Sobrepago de UI (Español)

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