Kansas Withholding from
K- 4U 
(Rev. 5/11)                              Unemployment Insurance Benefits 

Unemployment benefits you receive are considered taxable income for federal and state income tax purposes. To 
authorize state tax withholding from your benefits, complete this form and mail or fax it to the unemployment call center 
(see address and fax number below). 

Print your first name and middle initial              Last Name                               Social Security Number 

Mailing  Address 

City                                                                       State              ZIP Code 

I authorize the Kansas Department of Labor to withhold 3.5% of my weekly unemployment insurance benefit to be 
remitted to the Kansas Department of Revenue for my state income tax obligation. I understand the deduction will be 
made from benefits paid to me after the date of this agreement or as soon as is reasonable for the Kansas Department 
of Labor to update my file to reflect this agreement. 

This authorization will remain in effect until the Kansas Department of Labor receives        written  notice from me to 
cancel the agreement. 

CLAIMANT’S
                                                                                        DATE: 
SIGNATURE   ` 

CANCELLATION 

I hereby cancel my authorization for the Kansas Department of Labor to deduct 3.5% of my weekly unemployment 
insurance benefit for my Kansas income tax obligation. I understand this action will be effective the date of the agreement 
or as soon as is reasonable for the Kansas Department of Labor to update my file to reflect the change. 

CLAIMANT’S
                                                                                        DATE: 
SIGNATURE   ` 

MAILING ADDRESS / FAX NUMBER 

Kansas Unemployment Contact Center 
P.O. Box 3539 
Topeka KS 66601-3539 
Fax: (785) 296-3249