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Pension 1099

This document is a pension statement form from the Kansas Department of Labor that must be completed and returned within seven days of filing an unemployment claim. It requires information about the claimant's pension, retirement benefits, and contributions, along with supporting documentation. Failure to submit the form on time may lead to denial of benefits or overpayment issues.

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66 views1 page

Pension 1099

This document is a pension statement form from the Kansas Department of Labor that must be completed and returned within seven days of filing an unemployment claim. It requires information about the claimant's pension, retirement benefits, and contributions, along with supporting documentation. Failure to submit the form on time may lead to denial of benefits or overpayment issues.

Uploaded by

truckmancliff
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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KANSAS DEPARTMENT OF LABOR

www.dol.ks.gov MAIL: Unemployment Contact Center


P.O. Box 3539
PENSION STATEMENT Topeka, KS 66601-3539
K-BEN 3113 Web (Rev. 3-14)
FAX: (785) 296-3249

EMAIL*: KDOLforms@dol.ks.gov

Complete this form and return it within seven days of the date you iled your claim. Failure to reply by this date may result
in a denial of beneits or possible overpayment.

The Kansas Employment Security Law requires that certain pensions and retirement beneits be deducted from
unemployment insurance payments.

IMPORTANT: Attach a copy of documentation from your former employer or pension administrator supporting the
amount of your IRA/pension/retirement pay, date it started and the percentage or dollar amount contributed to the
pension/retirement beneit.

Claimant name: _______________________________________________________


Victoria Lynn Clines Social Security number: _______________________
415-13-2679

General Services Administration


Name of employer from whom you retired: _____________________________________________________________________________

1800 F St. NW, Denver , CO 80210, US


Employer’s mailing address: ________________________________________________________________________________________

Date you RECEIVED your irst pension check or partial/lump sum payment (mm/dd/yyyy): _______________________________________
08/23/2021

RETIREMENT DISABILITY Percentage or $ Amount Percentage or $ Amount


TYPE OF PAYMENT
(gross amount per month) (gross amount per month) Contributed by Employer You Contributed

FEDERAL SERVICE $ 2,750.00 $ 15.00 $ 302.50 $ 22.00


CITY, COUNTY, STATE (i.e., KPERS) $ $
MILITARY $ $
Military discharge date (mm/dd/yyyy): ______________________________ Did you complete 20 years military service? c YES c NO
If you are receiving military disability, is your check issued by the Veterans Administration? c YES c NO

COMPANY/CORPORATION $ $
UNION(S) $ $

Employer(s) that paid into the union(s) pensions: ___________________________________________________________________________________

IRA DISTRIBUTION (attach documentation): c Rollover (did NOT receive monies) c Received monies (indicate amount and date below)

Amount received: $ ___________________


2,713.00 01/31/2025
Date received (mm/dd/yyyy): _______________________

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.

( 302 ) 416-6554
Signature: ______________________________________________ Phone: ___________________________ 01/31/2025
Date: _________________

*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.

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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