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
