Form LO403.5 "Request for Rate Based on Weeks of Employment" - New York

What Is Form LO403.5?

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, 2019;
  • 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 LO403.5 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 LO403.5 "Request for Rate Based on Weeks of Employment" - New York

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PO Box 15130
Albany, NY 12212-5130
www.labor.ny.gov
Request for Rate Based on Weeks of Employment
To request a benefit rate based on weeks of employment, you must complete this form and return it to the above
Department of Labor address with a copy of your proof of employment and earnings for each week of employment for the
base period indicated below. It must be received within ten calendar days of the Date Mailed as stated on your most
recent Monetary Benefit Determination. Do not send the originals of your supporting payroll documents as they cannot be
returned. Your Request for Rate Based on Weeks of Employment cannot be processed until all Requests for
Reconsideration have been reviewed and the establishment of your base period has been finalized. You will be notified of
the action taken regarding your request within three weeks of receipt.
Complete only the front of this form if you have worked for one employer or you have worked for two or more employers
consecutively. If you worked during the same week(s) for two or more employers, complete the worksheet on the back of
this form first and transfer the appropriate information to the front of the form. If you have more than seven employers
during the base period, list the information on a separate sheet of paper and attach it to this form.
________________________________________Please print clearly________________________________________
Last Name: _____________________________________First name: _______________________Middle Initial: ______
Address: _________________________________________________________________________________________
City: ___________________________________________________ State: ________________ Zip: ______________
Social Security Number: XXX – XX - __ __ __ __
Base Period: From _______________________ Through _______________________
(Enter these dates from the previously issued T402, Monetary Benefit Determination)
A. Employer Name and Address
B. Length of Pay Period; i.e.
C. Total Weeks Paid
D. Total Wages Paid
weekly, bi-weekly, etc.
During Base Period
During Base Period
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
7.
$
E. Total Weeks and Wages Worked During the Base Period
$
F. Total Weeks Worked from Part 2 (on back)
G. Recomputation Formula:
1. Divide the total wages by the total weeks (the lesser of E or F) to calculate
the average weekly wage …………………………………………………………………………….$ ___________
2. Divide the average weekly wage by 2 to arrive at your proposed rate based
on weeks and wages. The rate cannot exceed $504.…………………………………………..…$ ___________
3. Enter your current benefit rate from your last T402 Monetary Benefit
Determination form ……………………………………………………………………………………$ ___________
4. Subtract line 3 from line 2. The amount must be $5 or more to receive
the recomputed rate based on weeks and wages…………………..……………………………...$ ___________
Certification: I certify that all information and records submitted are true and accurate. I understand that this
information is subject to verification and penalties can be imposed for false statements.
Signature: ___________________________________ Date: ____/____/________ Telephone No.: _________________
LO 403.5 (9/19)
PO Box 15130
Albany, NY 12212-5130
www.labor.ny.gov
Request for Rate Based on Weeks of Employment
To request a benefit rate based on weeks of employment, you must complete this form and return it to the above
Department of Labor address with a copy of your proof of employment and earnings for each week of employment for the
base period indicated below. It must be received within ten calendar days of the Date Mailed as stated on your most
recent Monetary Benefit Determination. Do not send the originals of your supporting payroll documents as they cannot be
returned. Your Request for Rate Based on Weeks of Employment cannot be processed until all Requests for
Reconsideration have been reviewed and the establishment of your base period has been finalized. You will be notified of
the action taken regarding your request within three weeks of receipt.
Complete only the front of this form if you have worked for one employer or you have worked for two or more employers
consecutively. If you worked during the same week(s) for two or more employers, complete the worksheet on the back of
this form first and transfer the appropriate information to the front of the form. If you have more than seven employers
during the base period, list the information on a separate sheet of paper and attach it to this form.
________________________________________Please print clearly________________________________________
Last Name: _____________________________________First name: _______________________Middle Initial: ______
Address: _________________________________________________________________________________________
City: ___________________________________________________ State: ________________ Zip: ______________
Social Security Number: XXX – XX - __ __ __ __
Base Period: From _______________________ Through _______________________
(Enter these dates from the previously issued T402, Monetary Benefit Determination)
A. Employer Name and Address
B. Length of Pay Period; i.e.
C. Total Weeks Paid
D. Total Wages Paid
weekly, bi-weekly, etc.
During Base Period
During Base Period
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
7.
$
E. Total Weeks and Wages Worked During the Base Period
$
F. Total Weeks Worked from Part 2 (on back)
G. Recomputation Formula:
1. Divide the total wages by the total weeks (the lesser of E or F) to calculate
the average weekly wage …………………………………………………………………………….$ ___________
2. Divide the average weekly wage by 2 to arrive at your proposed rate based
on weeks and wages. The rate cannot exceed $504.…………………………………………..…$ ___________
3. Enter your current benefit rate from your last T402 Monetary Benefit
Determination form ……………………………………………………………………………………$ ___________
4. Subtract line 3 from line 2. The amount must be $5 or more to receive
the recomputed rate based on weeks and wages…………………..……………………………...$ ___________
Certification: I certify that all information and records submitted are true and accurate. I understand that this
information is subject to verification and penalties can be imposed for false statements.
Signature: ___________________________________ Date: ____/____/________ Telephone No.: _________________
LO 403.5 (9/19)
Request for Rate Based on Weeks of Employment
Part 2 - Record of Concurrent Employment in Base Period
SS# XXX – XX - __ __ __ __ NAME: __________________________________________________ Base Period: From ___/___/_____ Thru ___/___/_____
Weeks 
*
Employer
PHOTOCOPY THIS FORM IF YOU WORKED FOR MORE THAN 7 EMPLOYERS DURING YOUR BASE PERIOD
INSTRUCTIONS:
*
1.
List all week ending dates (Sunday) for your entire base period. See T402 – Monetary Benefit Determination for dates of your base period.
2.
Enter a check mark () in the chart above for each week in which you worked for each base period employer.
3.
Total the number of weeks for each employer and enter on the front of this form with the wages for each employer.
4.
Using chart above, count each week for which you have entered a checkmark. Count each week only once even if you have more than
one checkmark for that week. This will be your total weeks of employment in your base period. Enter this amount here
and
on “Total Weeks Worked Part 2,” line “F” on the front of this form.
Photocopy & enclose proof of employment for all weeks worked for each employer. Do not send original documents.
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