Form TC403 HA "Unemployment Insurance Request for Alternate Base Period" - New York

What Is Form TC403 HA?

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 HA 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 HA "Unemployment Insurance Request for Alternate Base Period" - New York

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Department of Labor
IMPORTANT!
PO Box 15130
We sent you a Monetary Benefit Determinations showing the weekly
Albany, New York 12212-5130
benefits you will receive. Those benefits are based on your wages. If
www.labor.ny.gov
you believe some of your wages were missed, please complete this
Unemployment Insurance
form. This form must be received by us within 10 calendar days of the
Date Mailed as stated on your most recent Monetary Benefit
Request for Alternate Base Period
Determination notice. Please print clearly. If we cannot read your
writing, we cannot process this form.
Please print
Last Name:______________________________ First Name:___________________ Middle Initial: ______
clearly
Address:______________________________________________________________________________
City:_________________________________________ State: ___________ Zip Code:________________
Claim Ef fective/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 by the Response Due Date noted above. Please print
clearly. If you do not, we cannot process this form.
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
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 information
Wage
f or 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 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
This notice and all attachments must be received within the time frame noted above in the IMPORTANT! message.
Return
OR
MAIL: New York State
OR
ONLINE:
www.labor.ny.gov/signin
FAX: (518) 457-9378
Instructions
Department of Labor
Submit via online account messaging
This notice is your cover page.
PO Box 15130
system. Select “Submit Documents” and
Indicate total # of pages_____
Albany, New York 12212-5130
then “Submit Wage Documents”. Use
subject line “Wage Documentation”.
Claim weekly benefits at
www.labor.ny.gov
For more information visit:
For help, see the claimant handbook at
or call Tel-Service at (888) 581-5812.
www.labor.ny.gov
www.labor.ny.gov/uihandbook.
TC 403 HA (09/20)
Department of Labor
IMPORTANT!
PO Box 15130
We sent you a Monetary Benefit Determinations showing the weekly
Albany, New York 12212-5130
benefits you will receive. Those benefits are based on your wages. If
www.labor.ny.gov
you believe some of your wages were missed, please complete this
Unemployment Insurance
form. This form must be received by us within 10 calendar days of the
Date Mailed as stated on your most recent Monetary Benefit
Request for Alternate Base Period
Determination notice. Please print clearly. If we cannot read your
writing, we cannot process this form.
Please print
Last Name:______________________________ First Name:___________________ Middle Initial: ______
clearly
Address:______________________________________________________________________________
City:_________________________________________ State: ___________ Zip Code:________________
Claim Ef fective/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 by the Response Due Date noted above. Please print
clearly. If you do not, we cannot process this form.
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
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 information
Wage
f or 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 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
This notice and all attachments must be received within the time frame noted above in the IMPORTANT! message.
Return
OR
MAIL: New York State
OR
ONLINE:
www.labor.ny.gov/signin
FAX: (518) 457-9378
Instructions
Department of Labor
Submit via online account messaging
This notice is your cover page.
PO Box 15130
system. Select “Submit Documents” and
Indicate total # of pages_____
Albany, New York 12212-5130
then “Submit Wage Documents”. Use
subject line “Wage Documentation”.
Claim weekly benefits at
www.labor.ny.gov
For more information visit:
For help, see the claimant handbook at
or call Tel-Service at (888) 581-5812.
www.labor.ny.gov
www.labor.ny.gov/uihandbook.
TC 403 HA (09/20)