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Get NY TC 403 HA 2020-2024

Department of Labor PO Box 15130 Albany New York 12212-5130 www. labor. ny. gov Unemployment Insurance Request for Alternate Base Period Please print clearly IMPORTANT We sent you a Monetary Benefit Determinations showing the weekly benefits you will receive. Those benefits are based on your wages. If you believe some of your wages were missed please complete this form* This form must be received by us within 10 calendar days of the Date Mailed as stated on your most recent Monetary Benefit Determination notice. Please print clearly. If we cannot read your writing we cannot process this form* Last Name First Name Middle Initial Address City State Zip Code Claim Effective/Start Date // Social Security XXX XX - Form requirements If you wish to use the Alternate Base Period to increase your weekly benefit rate 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 8 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 by the Response Due Date noted above. 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 Last Calendar Quarter Information The last completed calendar quarter prior to your claim effective/start date is // through // Step 2 Wage Complete the information below include proof of wages and attach an additional page if you have information for more than 3 three employers. Month/Day/Year Refer to your Monetary Benefit Determination for calendar quarter dates and compare the Alternate Base Period Quarter wages with your records then check the appropriate box below and proceed to the Step indicated* The Alternate Base Period Quarter Wages are incorrect or missing* Proceed to Step 2 Employer Name Quarterly Gross Wages Employer Address If work was performed outside New 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 making Acknowledgement 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 Return Instructions This notice and all attachments must be received within the time frame noted above in the IMPORTANT message. FAX 518 457-9378 OR MAIL New York State Department of Labor This notice is your cover page. Indicate total of pages Claim weekly benefits at www.

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