Form TC403 HR "Unemployment Insurance Request for Reconsideration" - New York

What Is Form TC403 HR?

This is a legal form that was released by the New York State Department of Labor - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the New York State Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form TC403 HR by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download Form TC403 HR "Unemployment Insurance Request for Reconsideration" - New York

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Department of Labor
PO Box 15130
IMPORTANT!
Albany, NY 12212-5130
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 30 calendar days of the Date Mailed as stated on
your most recent Monetary Benefit Determination notice. Please print clearly. If we cannot read your
Unemployment Insurance
writing, we cannot process this form.
Request for Reconsideration
Please print clearly
Last Name:___________________________________ First Name: ___________________ Middle Initial:____
Address:__________________________________________________________________________________
City:_____________________________________________ State:______________ Zip Code:____________
Claim Ef fective/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.
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 / quarter indicated. Refer to
information for more than (3) three employers.
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,
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
indicate state: _______
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
Employer: _________________________________
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
Address:__________________________________
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
City: _________________ State: ____ Zip:_______
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
If work was performed outside New York State,
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
indicate state: _______
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.
OR Online: www.labor.ny.gov/signin. Submit via online account messaging system. Select “Submit Documents” and then “Submit
Wage Documents”. Use subject line “Wage Documentation”.
For help, see the claimant handbook at
Claim weekly benefits at www.labor.ny.gov
For more information visit:
www.labor.ny.gov.
www.labor.ny.gov/uihandbook.
or call Tel-Service at 888-581-5812.
TC 403 HR (09/20)
Department of Labor
PO Box 15130
IMPORTANT!
Albany, NY 12212-5130
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 30 calendar days of the Date Mailed as stated on
your most recent Monetary Benefit Determination notice. Please print clearly. If we cannot read your
Unemployment Insurance
writing, we cannot process this form.
Request for Reconsideration
Please print clearly
Last Name:___________________________________ First Name: ___________________ Middle Initial:____
Address:__________________________________________________________________________________
City:_____________________________________________ State:______________ Zip Code:____________
Claim Ef fective/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.
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 / quarter indicated. Refer to
information for more than (3) three employers.
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,
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
indicate state: _______
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
Employer: _________________________________
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
Address:__________________________________
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
City: _________________ State: ____ Zip:_______
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
If work was performed outside New York State,
Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___
indicate state: _______
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.
OR Online: www.labor.ny.gov/signin. Submit via online account messaging system. Select “Submit Documents” and then “Submit
Wage Documents”. Use subject line “Wage Documentation”.
For help, see the claimant handbook at
Claim weekly benefits at www.labor.ny.gov
For more information visit:
www.labor.ny.gov.
www.labor.ny.gov/uihandbook.
or call Tel-Service at 888-581-5812.
TC 403 HR (09/20)