Form Lo 403.5 Request For Rate Based On Weeks Of Employment Page 2

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Concurrency Worksheet
Record of Concurrent Employment in Base Period
SS# XXX – XX - __ __ __ __ NAME: __________________________________________________ Base Period: From ___/___/_____ Thru ___/___/_____
Weeks 
*
Employer
PHOTOCOPY THIS FORM IF YOU WORKED FOR MORE THAN 7 EMPLOYERS DURING YOUR BASE PERIOD
INSTRUCTIONS:
*
1.
List all week ending dates (Sunday) for your entire base period. See T402 – Monetary Benefit Determination for dates of your base period.
2.
Enter a check mark () in the chart above for each week in which you worked for each base period employer.
3.
Total the number of weeks for each employer and enter on the front of this form with the wages for each employer.
4.
Using chart above, count each week for which you have entered a checkmark. Count each week only once even if you have more than
one checkmark for that week. This will be your total weeks of employment in your base period. Enter this amount here
and
on “Total Weeks Worked from Concurrency Worksheet,” line “F” on the front of this form.
Photocopy & enclose proof of employment for all weeks worked for each employer. Do not send original documents.

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