NEW YORK STATE IMPORTANT!

DEPARTMENT OF LABOR This form must be received within ten

P. O. Box 15130 calendar days from the Date Mailed of
ALBANY, NY 12212-5130
your last Monetary Benefit Determination.
UNEMPLOYMENT INSURANCE Please print clearly. If you do not, we
cannot process this form.
Request for Alternate Base Period
Please print Brown Georgina
LAST NAME:______________________________ FIRST NAME:____________ MIDDLE INITIAL: ______
clearly
107 troutman street
ADDRESS:____________________________________________________________________________
Brooklyn
CITY: ________________________________________ NY
STATE: ___________ 11206
ZIP CODE:____________
CLAIM EFFECTIVE/START DATE: ____/____/____
0 3 0 1 2 0 SOCIAL SECURITY #: XXX – XX - __
8 __
7 __
2 __
5
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 within the time frame noted above in the
IMPORTANT! message. Please print clearly.
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 03/01/2021 through ____/___/____
The last completed calendar quarter prior to your claim effective/start date is: ____/___/____ 03/06/2022
Last Calendar Month/Day/Year Month/Day/Year
Quarter Refer to your Monetary Benefit Determination for calendar quarter dates and compare the Alternate Base Period
Information Quarter wages with your records, then check the appropriate box below and proceed to the "Step" indicated.
 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
Wage information for 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
Acknowledgement making false statements. I understand if I use the Alternate Base Period, these wages cannot be used for a future claim.
Verified by PDFFiller
03/09/2021

Georgina Brown
______________________________________________ 03/09/2021 ________
______________ 917 - 870 1372
_______ - _____________
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 FAX: 518-457-9378 OR MAIL: New York State Department of Labor
Instructions This notice is your cover page. P.O. Box 15130
Indicate total # of pages _____ Albany, NY 12212-5130
Claim your weekly benefits on the For additional information visit For assistance, review your
web or by calling Tel-Service. our website: www.labor.ny.gov claimant handbook.
TC 403 HA (10-15)