KANSAS DEPARTMENT OF LABOR
www.dol.ks.gov
WORKED FULL TIME
K-BEN 230 (Rev. 2-21)
Claimant Name: Social Security No.
MAIL: Unemployment Contact Center
P.O. Box 3539
Topeka, KS 66601-3539
FAX: (785) 296-3249
UPLOAD:
https://UIAssistance.GetKansaBenefits.gov
Complete this form and return it within seven days of the date you filed your claim.
Failure to reply by this date may
result in a denial of benefits, possible overpayment and collection of benefits previously received.
Our office has received information that you worked 40 or more hours during the week being claimed. Provide complete
details below concerning work performed during the week claimed. Without the requested information, a determination of
your eligibility for benefits for the week claimed will be based upon information presently available.
Payment of benefits
for the week claimed has been suspended pending receipt of this information.
Employer for whom you worked:
______________________________________________________________________________
Address:
__________________________________________
City:
________________________
State:
______
ZIP:
__________
Date you began employment (mm/dd/yyyy):
____________________________________________________________________
Number of hours worked during the week claimed:
_______________________
Hourly wages: $
__________
____________
Are you working for this employer?
YES
NO If NO, indicate below the reason you are no longer working:
Quit
Fired
Leave of Absence
Lack of work
Labor Dispute
If you have left this employment
, you will need to file an unemployment application before you will be able to claim any
more weekly benefits. You must work less than full time and earn less than your weekly benefit amount to be eligible to
claim weekly benefits. If you wish to file an unemployment application, you may do so at
www.GetKansasBenefits.gov
or through the Unemployment Contact Center in your area at one of the phone numbers listed below.
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.
Signature: _________________________________________________________ Date (mm/dd/yyyy): _________________
_
______
Phone: _______________________________________
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
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