Form Tc 403 Hr - Unemployment Insurance Request For Reconsideration
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1IMPORTANT!
New York State Department of Labor
PO Box 15130
This form must be received within 30
Albany, NY 12212-5130
calendar days from the Date Mailed of
your last Monetary Benefit Determination.
Please print clearly. If you do not, we
Unemployment Insurance
cannot process this form.
Request for Reconsideration
Please print clearly
Last Name:___________________________________ First Name: ___________________ Middle Initial:____
Address:__________________________________________________________________________________
City:_____________________________________________ State:______________ Zip Code:____________
Claim Effective/Start Date:____/___/_____ Social Security number: XXX-XX-___ ___ ___ ___
Form requirements
To correct wages and/or add wages not reflected on your Monetary Benefit Determination, follow the instructions below.
• Complete the employer and quarterly wage information 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.
• Do not send originals; photocopy all supporting documentation onto 8½ x 11 single-sided paper.
• Write your name, the last four digits of your Social Security number and your phone number on each attachment.
• If you received worker’s compensation, include a copy of your most recent Subsequent Report of Injury (SROI) filing.
• This completed form and all attachments must be received within the time frame noted above in the IMPORTANT!
message. Please print clearly.
Employer Information
Basic or Alternate Base Period Total Quarterly Gross Wages
Please print clearly. Attach an additional page if you have
Write in the total quarterly gross wages for each employer /
information for more than (3) three employers.
quarter indicated. Refer to your most recent Monetary Benefit
Determination for assistance.
$
,
.
Employer: __________________________________
Quarter ___/___/_____ - ___/___/_____
Address:____________________________________
$
,
.
Quarter ___/___/_____ - ___/___/_____
City: __________________ State: ____ Zip:_______
$
,
.
Quarter ___/___/_____ - ___/___/_____
If work was performed outside New York State,
$
,
.
Quarter ___/___/_____ - ___/___/_____
indicate state: _______
$
,
.
Quarter ___/___/_____ - ___/___/_____
$
,
.
Employer: __________________________________
Quarter ___/___/_____ - ___/___/_____
$
,
.
Address:____________________________________
Quarter ___/___/_____ - ___/___/_____
City: __________________ State: ____ Zip:_______
$
,
.
Quarter ___/___/_____ - ___/___/_____
If work was performed outside New York State,
$
,
.
indicate state: _______
Quarter ___/___/_____ - ___/___/_____
$
,
.
Quarter ___/___/_____ - ___/___/_____
$
,
.
Employer: __________________________________
Quarter ___/___/_____ - ___/___/_____
$
,
.
Address:____________________________________
Quarter ___/___/_____ - ___/___/_____
City: __________________ State: ____ Zip:_______
$
,
.
Quarter ___/___/_____ - ___/___/_____
If work was performed outside New York State,
$
,
.
indicate state: _______
Quarter ___/___/_____ - ___/___/_____
$
,
.
Quarter ___/___/_____ - ___/___/_____
Certification
I certify that the above information is true to the best of my knowledge and I am aware that there are penalties for
making false statements. I understand I will be notified of the results of my request.
___________________________________________ ________________ _____________________
Signature (Required)
Date
Area code Telephone number
Return instructions
This notice and all attachments must be received within the time frame noted above in the IMPORTANT! message.
Fax: 518-457-9378. This notice is your cover page. Indicate total number of pages ______.
OR Mail: New York State Department of Labor, P.O. Box 15130, Albany, NY 12212-5130.
Claim weekly benefits at
For more information visit:
For help, see the claimant handbook at
or call Tel-Service at 888-581-5812.
.
/uihandbook.
TC 403 HR (10-15)
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