Division of Unemployment Insurance Go online: coloradoui.

gov
P.O. Box 400 Call: 1-800-388-5515
Denver, CO 80201-0400Fax: 303-318- 9014

Forwarding Service Requested

Kenneth M. Kostuck
c/o KEN M
5 E Bijou St #305 June 28, 2021
Colorado Springs, CO 80903-1301 Claimant ID: 10221275

IMPORTANT! The following information is needed to determine if you can be paid unemployment benefits. It
is critical that you understand the information in this document. If a question does not apply, state that in your
answer. There is room at the bottom to add more information, if necessary. Complete and submit this
questionnaire no later than 7/6/2021. If returned by mail, your response must be received no later than 7/6/2021.
If you do not respond by the due date, we will issue a decision based on the available information. If you need
help understanding or with the translation of the information in this document, call 1-800-388-5515.

¡IMPORTANTE! La siguiente información es necesaria para determinar si se le puede pagar beneficios de

desempleo. Es sumamente importante que usted comprenda la información de este documento. Si una pregunta
no aplica, declare que no aplica en su respuesta. Si es necesario, hay espacio en la parte inferior para añadir más
información. Complete y envíe este cuestionario antes del 7/6/2021. Si se lo devuelve por correo, su respuesta
debe recibirse a más tardar el 7/6/2021. Si no responde para la fecha de vencimiento, emitiremos una decisión
basada en la información disponible. Si necesita ayuda para comprender o con la traducción de la información
de este documento, llame al 1-800-388-5515.

Section 1
It has been reported that you are engaged in or plan to enter self-employment.

1. Are you currently self-employed, or do you own a business of any kind that stops you from looking for or
accepting work outside of your business? Yes
*
No
2. What is the name and address of the business?
rehabitate ltd 5 E Bijou St. #305 *
3. _________________________________________________________What is the nature of your self-
employment?
Handyman, painting, Residential construction. *

4. _________________________________________________________What type of business is this? *

Independent Business Enterprise
Sole Proprietorship

An Equal Opportunity Employer Page 1 of 4

IMPORTANTE: Este documento afecta su elegibilidad para recibir beneficios de Seguro de Desempleo. Si usted no entiende este
documento, llame inmediatamente a la lÃnea de servicio al cliente del Departamento de Trabajo y Empleo de Colorado al 1-800-388-
5515.
 45379086
Partnership
Corporation
1099 Employment
Other (yard work, babysitting, etc.) 5. What was the beginning
date of your business? 4/23/2021 *
6. What is the number of employees working for you?
1 *

7. _________________________________________________________Briefly tell us about the duties you are

required to perform:
I bid the jobs, I look for the work to be bid on. I handle all the work that is done. painting, building, *
framing etc. I filed all the paperwork for the business, I made the website, I do all the taxes,
paperwork anything to do with the business.
8. _________________________________________________________Do you set your own hours?
Yes
*
No
9. What days of the week are you required to perform these duties? Please list the number of hours you spend
performing these duties each day. *

An Equal Opportunity Employer Page 2 of 4

IMPORTANTE: Este documento afecta su elegibilidad para recibir beneficios de Seguro de Desempleo. Si usted no entiende este
documento, llame inmediatamente a la lÃnea de servicio al cliente del Departamento de Trabajo y Empleo de Colorado al 1-800-388-
5515.
 45379086
13a. If no, please explain in detail.

_________________________________________________________
Colorado law requires that applicants for unemployment benefits be physically capable of work during any week
claimed, prepared to go to work during any week claimed and actively looking for work. Failure to meet the
aforementioned criteria may result in a denial of benefits.
I understand that if I am not physically capable of work during any week claimed, prepared to go to work
during any week claimed and actively looking for work my benefits may be denied for that week. I have
provided honest and correct information.*

Section 2
If you wish to provide any additional information about this issue, provide below.
my IRS filing number is 86-3440196, I have been incorporated in Colorado since 04/23/2021
_________________________________________________________Name and title of the person completing
this request:
Ken Kostuck, owner of rehabitate ltd. *

_________________________________________________________Telephone number of the person

completing this request: 4802891568
If you would like to be contacted by email as an additional method to contact you, please provide your email
address: kostuck71@gmail.com
I certify that the above information is true and correct and I understand that the law provides penalties for
false information.*

An Equal Opportunity Employer Page 3 of 4

IMPORTANTE: Este documento afecta su elegibilidad para recibir beneficios de Seguro de Desempleo. Si usted no entiende este
documento, llame inmediatamente a la lÃnea de servicio al cliente del Departamento de Trabajo y Empleo de Colorado al 1-800-388-
5515.
 45379086

An Equal Opportunity Employer Page 4 of 4

IMPORTANTE: Este documento afecta su elegibilidad para recibir beneficios de Seguro de Desempleo. Si usted no entiende este
documento, llame inmediatamente a la lÃnea de servicio al cliente del Departamento de Trabajo y Empleo de Colorado al 1-800-388-
5515.