Form TC 403HA at a glance
What it is: Unemployment Insurance Request for Alternate Base Period: use it if you wish to use the Alternate Base Period to increase your weekly benefit rate.
Where and when to file: This form must be received within ten calendar days from the Date Mailed of your last Monetary Benefit Determination. Fax: 518-457-9378 or Mail: New York State Department of Labor, P.O. Box 15130, Albany, NY 12212-5130. This notice is your cover page. Indicate total # of pages.
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.
What to bring and attach to Form TC 403HA
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.
A filled-in Form TC 403HA example: a claimant lists one employer
How to fill out Form TC 403HA, box by box
Please print clearly
Please print clearly. If you do not print clearly, this form cannot be processed.
Enter your Last Name, First Name, Middle Initial, Address, City, State and Zip Code.
Enter the Claim Effective/Start Date, then the Social Security number after XXX-XX-.
Step 1 Last Calendar Quarter Information
Under Step 1, Last Calendar Quarter Information, enter the dates of the last completed calendar quarter prior to your claim effective/start date. 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 and proceed to the "Step" indicated.
If the Alternate Base Period Quarter Wages are incorrect or missing, check that box and proceed to Step 2. If the Alternate Base Period Quarter Wages are correct, check that box and proceed to Step 3.
Step 2 Wage Information
In Step 2, complete the information, include proof of wages and attach an additional page if you have information for more than (3) three employers.
For the first employer, enter the Employer Name, Quarterly Gross Wages, Employer Address, City, State and Zip. If work was performed outside New York State, indicate state.
For each other employer, enter the same Employer Name, Quarterly Gross Wages, Employer Address, City, State and Zip, and the state if work was performed outside New York State.
Step 3 Acknowledgement
Under Step 3, Acknowledgement, you certify that the information is true to the best of your knowledge and are aware that there are penalties for making false statements. You understand that if you use the Alternate Base Period, these wages cannot be used for a future claim. Sign on the Signature Required line, then enter the Date, Area code and Telephone number.
Step 4 Return Instructions
Under Step 4, the completed form and all attachments must be received within the time frame noted in the IMPORTANT! message.
Before you go
Complete the steps using black or blue ink.
Sources
[1] Form TC 403HA (12/25), Unemployment Insurance Request for Alternate Base Period, New York State Department of Labor (the Official source link on this page).