Form Tc 403 Ha - Unemployment Insurance Request For Alternate Base Period printable pdf download

NEW YORK STATE

IMPORTANT!

DEPARTMENT OF LABOR

This form must be received within ten

P. O. Box 15130

calendar days from the Date Mailed of

ALBANY, NY 12212-5130

your last Monetary Benefit Determination.

UNEMPLOYMENT INSURANCE

Please print clearly. If you do not, we

cannot process this form.

Request for Alternate Base Period

Please print

LAST NAME:______________________________ FIRST NAME:____________ MIDDLE INITIAL: ______

clearly

ADDRESS:____________________________________________________________________________

CITY: ________________________________________ STATE: ___________ ZIP CODE:____________

CLAIM EFFECTIVE/START DATE: ____/____/____ SOCIAL SECURITY #: XXX – XX - __ __ __ __

Form

If you wish to use the Alternate Base Period to increase your weekly benefit rate:

requirements

•

Complete the steps below using black or blue ink.

•

Include any documentation that could be considered proof of employment and wages such as pay

stubs, W-2s, 1099s, vouchers, checks, tips, bonuses, meals, lodging, commissions, vacation pay

and records of employment and/or payment.

•

Photocopy all supporting documentation onto 8½ x 11 single-sided paper. Do not send originals.

•

Write your name, the last four digits of you Social Security number and your phone number on each

attachment.

•

This completed form and all attachments must be received within the time frame noted above in the

IMPORTANT! message. Please print clearly.

If the wages in your last completed calendar quarter exceed the "High Quarter Wages" on your

Monetary Benefit Determination, use of the Alternate Base Period may increase your benefit rate. If

you choose the Alternate Base Period to establish a claim, you will not be able to use these wages

for a future claim.

Step 1

The last completed calendar quarter prior to your claim effective/start date is: ____/___/____ through ____/___/____

Last Calendar

Month/Day/Year

Refer to your Monetary Benefit Determination for calendar quarter dates and compare the Alternate Base Period

Quarter

Quarter wages with your records, then check the appropriate box below and proceed to the "Step" indicated.

Information



The Alternate Base Period Quarter Wages are incorrect or missing. (Proceed to Step 2)



The Alternate Base Period Quarter Wages are correct. (Proceed to Step 3)

Step 2

Complete the information below, include proof of wages and attach an additional page if you have

Wage

information for more than (3) three employers.

Information

EMPLOYER NAME:_______________________________QUARTERLY GROSS WAGES $___________

EMPLOYER ADDRESS: ________________________________________________________________

If work was performed outside New

CITY:____________________________STATE:____________ZIP:__________

York State, indicate state _______

EMPLOYER NAME:_______________________________QUARTERLY GROSS WAGES $___________

EMPLOYER ADDRESS: ________________________________________________________________

If work was performed outside New

CITY:____________________________STATE:____________ZIP:__________

York State, indicate state _______

EMPLOYER NAME:_______________________________QUARTERLY GROSS WAGES $___________

EMPLOYER ADDRESS: ________________________________________________________________

If work was performed outside New

CITY:____________________________STATE:____________ZIP:__________

York State, indicate state _______

Step 3

I certify that the above information is true to the best of my knowledge and I am aware that there are penalties for

Acknowledgement

making false statements. I understand if I use the Alternate Base Period, these wages cannot be used for a future claim.

______________________________________________ ______________ ________ - _______ - _____________

Signature Required

Date

Area Code

Telephone Number

Step 4

This notice and all attachments must be received within the time frame noted above in the IMPORTANT! message.

Return

FAX: 518-457-9378

MAIL: New York State Department of Labor

Instructions

This notice is your cover page.

P.O. Box 15130

Indicate total # of pages _____

Albany, NY 12212-5130

Claim your weekly benefits on the

For additional information visit

For assistance, review your

web or by calling Tel-Service.

our website:

claimant handbook.

TC 403 HA (10-15)

Form Tc 403 Ha - Unemployment Insurance Request For Alternate Base Period

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