Form K-Ben 3110 - Claimant'S Separation Statement

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KANSAS DEPARTMENT OF LABOR
MAIL:
Unemployment Contact Center
CLAIMANT’S SEPARATION STATEMENT
P.O. Box 3539
Topeka, KS 66601-3539
K-BEN 3110 Web (Rev. 4-16)
FAX:
(785) 296-3249
EMAIL: KDOLforms@dol.ks.gov
– SEE INSTRUCTIONS ON PAGE 2 –
*See important email notice on website.
Claimant Name:
SSN:
The information you provide will be used to determine if you are qualified to receive benefits. Failure to provide ALL of
the requested information on this form at least three (3) days before your scheduled call may result in a denial of
benefits, possible overpayment and collection of benefits previously received.
Your mailing address: ____________________________________________________________________________________________
Last employer you physically worked for when claim was filed:_______________________________________________________________
(
)
Employer phone: _________________________ Employer mailing address: ________________________________________________
Your position/job title: _____________________________________________________________________________________________
Date began work (mm/dd/yyyy): ______________________________ Last physical day worked (mm/dd/yyyy): ______________________
Reason for separation:
c Discharged
c Quit
c Leave of Absence
c Labor Dispute
c Laid Off/Lack of Work
If leave of absence: Date began (mm/dd/yyyy): ___________________ Date returned to work (mm/dd/yyyy): _______________________
Explain in detail the final incident/event that led to your separation. If more space is needed, attach additional sheets and any supporting
documents. (See reverse side for details.)
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: _____________________________________________ Phone: ____________________________ Date: _________________
Submit
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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