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.
To use it: if you wish to use the Alternate Base Period to increase your weekly benefit rate, complete the steps below using black or blue ink.
Future claim: if you choose the Alternate Base Period to establish a claim, you will not be able to use these wages for a future claim.
Documents: include documentation that could be considered proof of employment and wages, such as pay stubs, W-2s, 1099s; do not send originals.
Employers: attach an additional page if you have information for more than 3 employers.
| Question | Answer |
|---|---|
| Form Name | TC 403HA |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 50 |
| Avg. time to fill out | 9 min |
| Edition | Rev 12/25 |
| Received within | Ten calendar days from the Date Mailed of your last Monetary Benefit Determination |
| Where to send | Fax 518-457-9378, or mail to New York State Department of Labor, PO Box 15130, Albany, NY 12212-5130 |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | TC 403HA, TC403HA, TC 403, TC 403 HA, Unemployment Insurance Request for Alternate Base Period |
| Official source | TC 403HA (Rev 12/25), New York State Department of Labor |
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