Form Tc403hr - Unemployment Insurance Request For Reconsideration Form
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1NEW YORK STATE
DEPARTMENT OF LABOR
PO Box 15130
ALBANY, NY 12212-5130
IMPORTANT!
Response must be received within (30)
UNEMPLOYMENT INSURANCE
thirty days from the Date Mailed of your
last Monetary Benefit Determination.
Request for Reconsideration
Complete the
NAME:____________________________________________
SOCIAL SECURITY #: ________ - ______ - ________
following
information
ADDRESS: ______________________________________________________________________________________
CITY: _____________________________________________ STATE: ____________ ZIP CODE: ______________
CLAIM EFFECTIVE / START DATE: _____ / _____ / _____
BENEFIT YEAR ENDING DATE: _____ / _____ / _____
To correct wages and/or add wages not reflected on your Monetary Benefit Determination, follow the instructions below.
Form
Complete the employer and quarterly wage information below using black or blue ink;
requirements
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Include any documentation that could be considered proof of employment and wages such as: pay stubs,
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W-2, 1099, 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;
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Write your Name, Social Security Number and Telephone Number on each attachment;
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If you received Worker s Compensation include a copy of your most recent C8 Form;
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This completed notice and all attachments must be received within the timeframe noted above in the
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IMPORTANT! message .
Employer Information
Basic or Alternate Base Period Total Quarterly Gross Wages
Please Print Clearly. Attach an additional page if you have information for Write in the total quarterly gross wages for each employer / quarter indicated.
more than (3) three employers.
Refer to your most recent Monetary Benefit Determination for assistance.
,
.
QUARTER ___/___/_____ - ___/___/_____
$
EMPLOYER: _________________________________________________
,
.
QUARTER ___/___/_____ - ___/___/_____
$
ADDRESS: __________________________________________________
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.
QUARTER ___/___/_____ - ___/___/_____
$
,
.
CITY: ___________________________ STATE: _____ ZIP: __________ QUARTER ___/___/_____ - ___/___/_____
$
,
.
QUARTER ___/___/_____ - ___/___/_____
If work was performed outside New York State, indicate State: ________
$
MM DD YYYY MM DD YYYY
,
.
$
QUARTER ___/___/_____ - ___/___/_____
EMPLOYER: _________________________________________________
,
.
QUARTER ___/___/_____ - ___/___/_____
$
ADDRESS: __________________________________________________
,
.
QUARTER ___/___/_____ - ___/___/_____
$
CITY: ___________________________ STATE: _____ ZIP: __________
,
.
QUARTER ___/___/_____ - ___/___/_____
$
If work was performed outside New York State, indicate State: ________
,
.
QUARTER ___/___/_____ - ___/___/_____
$
MM DD YYYY MM DD YYYY
,
.
$
QUARTER ___/___/_____ - ___/___/_____
EMPLOYER: _________________________________________________
,
.
$
QUARTER ___/___/_____ - ___/___/_____
ADDRESS: __________________________________________________
,
.
$
QUARTER ___/___/_____ - ___/___/_____
CITY: ___________________________ STATE: _____ ZIP: __________ QUARTER ___/___/_____ - ___/___/_____
,
.
$
,
.
If work was performed outside New York State, indicate State: ________ QUARTER ___/___/_____ - ___/___/_____
$
MM DD YYYY MM DD YYYY
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
Acknowledgment
statements. I understand I will be notified of the results of my request.
__________________________________________
__________________
________ - ________ - ___________
Signature Required
Date
Area Code
Telephone Number
This notice and all attachments must be received within the timeframe noted above in the IMPORTANT! message.
Return
Instructions
FAX: 518-457-9378
OR
MAIL: New York State Department of Labor
P.O. Box 15130
This notice is your cover page.
Albany, NY 12212-5130
Indicate total # of pages ____
For assistance, review your
Claim your weekly benefits on the web or
For additional information visit
by
calling
Tel-Service.
Claimant Handbook
our website:
TC403HR (6-09)
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