Fillable Kben3120A (Kansas Department of Labor)

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Kben3120A (Kansas Department of Labor)

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Complete this form and return it within seven days of the date you led your claim. Failure to reply by this date may result in
a denial of benets or possible overpayment.
MAIL: Unemployment Contact Center
P.O. Box 3539
Topeka, KS 66601-3539
FAX: (785) 296-3249
EMAIL*: Submit
KANSAS DEPARTMENT OF LABOR
www.dol.ks.gov
SELF-EMPLOYMENT STATEMENT
K-BEN 3120-A Web (Rev. 10-17)
Page 1 of 2
KANSAS UNEMPLOYMENT CONTACT CENTER
Kansas City Area (913) 596-3500 • Topeka Area (785) 575-1460 • Wichita Area (316) 383-9947 • All Other Areas (800) 292-6333
Claimant name: _______________________________________________________ Social Security number: _______________________
In what business or occupation are you self employed? ___________________________________________________________________
What are your job duties in this self employment? _______________________________________________________________________
Which tools do you use?
Own tools
Company’s tools
What types of tools are used? ______________________________________________________________________________________
What monetary investment does this self employment require? _____________________________________________________________
Do you own your own business?
YES
NO
Do you have a Federal Employer Identication Number (FEIN)?
YES
NO
Do you advertise?
YES
NO
How are you paid?
Hourly
Weekly
Monthly
When job is completed
Commission
Salary plus commission
Date you began self employment (mm/dd/yyyy): ____________________________
Are you currently involved in this activity?
YES How long will this self employment last? ____________________________________
NO Date self employment ended (mm/dd/yyyy): _________________________________
For whom are the services provided? _________________________________________________________________________________
Who sets your hours?
I set my own hours The company I work for sets my hours
What hours and days of the week do you perform this self employment? _____________________________________________________
_______________________________________________________________________________________________________________
Will this time vary from one week to another?
YES
NO
Can this self employment be performed after 5:00 p.m. each day?
YES
NO
Would you end self employment for regular employment?
YES
NO
Are you seeking and will you accept employment of 40 hours per week?
YES
NO
If YES, how would you accomplish this in addition to your self employment? __________________________________________________
_______________________________________________________________________________________________________________
KANSAS UNEMPLOYMENT CONTACT CENTER
Kansas City Area (913) 596-3500 • Topeka Area (785) 575-1460 • Wichita Area (316) 383-9947 • All Other Areas (800) 292-6333
Kansas Department of Labor
Self-Employment Statement
K-BEN 3120-A Web (Rev.
10-17)
Page 2 of 2
List your efforts to seek work in the past seven days:
Date of Contact Name of Employer Method of Contact Results of Contact
If no contacts were made, explain: ___________________________________________________________________________________
_______________________________________________________________________________________________________________
Additional information required if self employment is farming:
How many acres do you farm?__________________
How many acres are cultivated?_________________
How many acres are in pasture?_________________
During harvest and planting seasons, do you usually seek a leave of absence from your employer to carry on your farming activities?
YES
NO
If you are feeding livestock, can you give all attention needed to that activity before 7:00 a.m. and after 5:00 p.m.?
YES
NO
Claimant name: _______________________________________________________ Social Security number: _______________________
Type of work you’re seeking: _______________________________________________________________________________________
Do you have experience or training in this type of work?
YES
NO
How much experience? ___________years ___________months ___________days
Hours you’re willing to work: ________
AM
PM to ________
AM
PM Days per week: ______
Shifts you are willing to work (check all that apply):
First
Second
Third
If you are only willing to work one shift, explain why: _______________________________________________________________________
_______________________________________________________________________________________________________________
Signature: ____________________________________________ Phone: _____________________________ Date: _________________
( )
CERTIFICATION: I certify that the information I have provided is correct and complete, and I understand the willful or intentional
misrepresentation or failure to disclose a material fact is punishable under the Kansas Employment Security Law.
*NOTE: Protecting claimants’ identity is important to us. Please be advised that: (1) email communication is not a secure method of communication; (2)
any email that is sent between you and this agency may be copied and held by various computers it passes through as it is transmitted; (3) persons not
participating in the communication between you and KDOL may intercept the communication by improperly accessing your computer or this agency’s
computer or even some computer unconnected to either of us that this email passes through. If you do not want to communicate with KDOL through email,
please call KDOL or mail your communication to KDOL, instead of using email.
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Kben3120A (Kansas Department of Labor)

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Completed 18 July 2020

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