unemployment insurance claimant handbook tc318.3 (Part 4 of 4)

• You wish to file a new claim

Claims Center.* Advocates are not able to process claims, make determinations or expedite a claim.

• You would like an update on the status of your new or existing claim

• You have a specific question about your claim or weekly benefits

• You were instructed to contact the Telephone Claims Center

Contact the Claimant Advocate Office Hours of Operation: Monday - Friday, 9 a.m. to 4 p.m. Call toll-free: 855-528-5618 Services are available in approximately 200 languages by phone. When you call, please have:

• Your Social Security number

• A list of questions, and

• Any related documents

You may also send us a secure message (English only): Log in at labor.ny.gov/signin. On the My Online Services page, in the Messages section, click "Go to My Inbox." and choose “Compose New.” Select the “UI Claimant Advocate Office” for the subject line. Our office staff are not lawyers and cannot represent you at a hearing. If you cannot afford to pay an attorney or a registered representative, you may be able to get free representation from a pro bono attorney or a legal services program. For a list of legal resources, including attorneys, registered representatives, legal services programs and pro bono attorneys’ organizations, go to the Unemployment Insurance Appeal Board website at uiappeals.ny.gov. Click on the “Helpful Information” tab and then click on “Guides and Resources.” Choose the “List of Attorneys & Authorized Agents.” You may also request this list by calling 518-402-0205.

*To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370.

New York State Department of Labor

14 Appendix Ii: Sending A Secure

Message

Log in to our website with your NY.gov ID at labor.ny.gov/signin. If you do not already have an account, directions for creating one are on our website at labor.ny.gov/signin. If you have difficulty creating an NY.gov ID, see the illustrated instructions listed on the sign in page, check the NY.gov Frequently Asked Questions, or call 800-833-3000 Monday - Friday, 8:30 a.m. to 4:30 p.m.

Once you have signed in, on the My Online Services page, in the Messages section, click "Go to My Inbox." and then select “Compose New.” You will now need to choose a subject line. Click on the dropdown arrow next to the word “Subject” to see a list of subjects. Click on the subject line that best matches your question. When you do this, a second set of subject lines will appear. Again, choose the second subject line that best matches your question. This will ensure your message is sent to the correct staff member.

For more information, see our "How to Send a Secure Message" factsheet (P837), available at dol. ny.gov/forms-and-publications. For instructions on how to send specific types of secure messages, see the “Contact Us” section at the beginning of this handbook. *Disclaimer: In addition to recorded telephone calls, messages you send or receive by secure message may be used as evidence in a future hearing.

*To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call *To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370. 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370.

54 Unemployment Insurance: A BRIDGE TO YOUR NEXT CAREER Unemployment Insurance: A BRIDGE TO YOUR NEXT CAREER

Provide Complete and Accurate Information: Submit Your Claim. • If you give us incomplete or incorrect information, your claim and any payments that may be due to you could be delayed. • If you give us false information or withhold information, your future benefits will be lost or reduced and you may face other serious consequences including the possibility of prosecution.: Once you begin your application, always move forward until you are finished. You will lose information if you do any of the following before you submit your claim: • Exit the application • Lose your Internet connection • Use your browser’s “back” button You can look over, change or print your responses in the “Review of Application Responses” section. When you are done, select the “Submit Claim” button..

Provide Complete and Accurate Information: Keep Your Contact Information Current. • If you give us incomplete or incorrect information, your claim and any payments that may be due to you could be delayed. • If you give us false information or withhold information, your future benefits will be lost or reduced and you may face other serious consequences including the possibility of prosecution.: By signing up for an online account, you agree to keep the contact information you have given us up to date. This includes your mailing address (required) and email address (required). If your contact information changes, you agree to update that information for our records..

Provide Complete and Accurate Information: Respond to All Department Requests. • If you give us incomplete or incorrect information, your claim and any payments that may be due to you could be delayed. • If you give us false information or withhold information, your future benefits will be lost or reduced and you may face other serious consequences including the possibility of prosecution.: You agree to check and respond to messages and questionnaires we may send to through the NY.gov secure message system and all messages, forms and letters we send you by mail. You must respond within the time frames listed in those documents. You acknowledge and understand that if you fail to: • keep your contact information up-to-date • check your NY.gov secure message inbox, or • respond to our communications within the time frames listed in those documents Your benefits may be delayed, suspended or denied..

New York State Department of Labor

15 Appendix Iii: Online Filing Terms

And Conditions

When you use online services to file your claim, you must agree to the following terms and conditions: Provide Complete • If you give us incomplete or incorrect information, your claim and any and Accurate payments that may be due to you could be delayed. Information

• If you give us false information or withhold information, your future

benefits will be lost or reduced and you may face other serious consequences including the possibility of prosecution. Submit Your Claim Once you begin your application, always move forward until you are finished. You will lose information if you do any of the following before you submit your claim:

• Exit the application

• Lose your Internet connection

• Use your browser’s “back” button

You can look over, change or print your responses in the “Review of Application Responses” section. When you are done, select the “Submit Claim” button. Keep Your Contact By signing up for an online account, you agree to keep the contact Information Current information you have given us up to date. This includes your mailing address (required) and email address (required). If your contact information changes, you agree to update that information for our records.

Respond to All You agree to check and respond to messages and questionnaires we may Department send to through the NY.gov secure message system and all messages, forms Requests and letters we send you by mail. You must respond within the time frames listed in those documents. You acknowledge and understand that if you fail to:

• keep your contact information up-to-date

• check your NY.gov secure message inbox, or

• respond to our communications within the time frames listed in those

documents Your benefits may be delayed, suspended or denied. *To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370.

Keep Important Claim Information: Direct Deposit Option. After you submit your claim, you will see a “Confirmation Page” that lists additional information and instructions. • Print or write down the information on that page for future reference • If you do not follow these instructions, your payments may be delayed or lost If you want to keep a copy of your entire application, you may print each page at the “Review of Application Responses” section.: • Print or write down the “Direct Deposit Information Review” page information before submitting your direct deposit information. • This will be your only proof of the account information you provided..

Keep Important Claim Information: Call if Instructed. After you submit your claim, you will see a “Confirmation Page” that lists additional information and instructions. • Print or write down the information on that page for future reference • If you do not follow these instructions, your payments may be delayed or lost If you want to keep a copy of your entire application, you may print each page at the “Review of Application Responses” section.: Not all applications may be completed online. If you see a confirmation page that says you must speak with a claims specialist to complete your application for Unemployment Insurance benefits, you must call the Telephone Claims Center. The information you provide online will be saved. However, your claim will not be processed until you make that call..

Keep Important Claim Information: Keep Your PIN Secure. After you submit your claim, you will see a “Confirmation Page” that lists additional information and instructions. • Print or write down the information on that page for future reference • If you do not follow these instructions, your payments may be delayed or lost If you want to keep a copy of your entire application, you may print each page at the “Review of Application Responses” section.: ***NEVER Tell Anyone Your PIN (Personal Identification Number)*** When you submit a claim, you will be prompted to create a PIN. Your PIN is your electronic signature. You will use your PIN every time you access the claims processing system. You could lose up to 20 weeks of benefits if you allow another person to use your PIN. If you are a person with a disability who is unable to access our services without the help of another person, you may allow another person to help you. However, you must be present each time your helper uses our services, including when your helper enters your PIN. You are responsible for the actions of your helper. You may be subject to penalties, including forfeiture of benefits, if you are not present when your helper accesses our services. Note: Claimants are not required to use a helper for any services through the Department of Labor, including unemployment insurance. Interpretive services are available at no cost..

New York State Department of Labor Keep Important After you submit your claim, you will see a “Confirmation Page” that lists Claim Information additional information and instructions.

• Print or write down the information on that page for future reference

• If you do not follow these instructions, your payments may be delayed or

lost If you want to keep a copy of your entire application, you may print each page at the “Review of Application Responses” section. Direct Deposit • Print or write down the “Direct Deposit Information Review” page Option information before submitting your direct deposit information.

• This will be your only proof of the account information you provided.

Call if Instructed Not all applications may be completed online. If you see a confirmation page that says you must speak with a claims specialist to complete your application for Unemployment Insurance benefits, you must call the Telephone Claims Center. The information you provide online will be saved. However, your claim will not be processed until you make that call.

Keep Your PIN ***NEVER Tell Anyone Your PIN (Personal Identification Number)*** Secure When you submit a claim, you will be prompted to create a PIN. Your PIN is your electronic signature. You will use your PIN every time you access the claims processing system. You could lose up to 20 weeks of benefits if you allow another person to use your PIN.

If you are a person with a disability who is unable to access our services without the help of another person, you may allow another person to help you. However, you must be present each time your helper uses our services, including when your helper enters your PIN. You are responsible for the actions of your helper. You may be subject to penalties, including forfeiture of benefits, if you are not present when your helper accesses our services.

Note: Claimants are not required to use a helper for any services through the Department of Labor, including unemployment insurance. Interpretive services are available at no cost. *To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call *To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370. 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370.

56 Unemployment Insurance: A BRIDGE TO YOUR NEXT CAREER Unemployment Insurance: A BRIDGE TO YOUR NEXT CAREER

New York State Department of Labor 9 Things You Must 1. Report all hours you work. You must report any hours you work when Do When Filing for you claim your weekly UI benefits. This includes part-time, temporary or Unemployment unpaid jobs. Benefits 2. Be accurate. Carefully read all letters the Department of Labor sends to you. Follow the instructions and return all forms as soon as possible. This will help prevent delays in UI payments.

3. Be available to work. You must be able to take a job right away. Every week, you must verify that you were ready, willing and able to work. 4. Look for work. You must search for work each week and keep a written record of every employer you contact. See “What is considered systematic and sustained efforts to find work” in Chapter 7 or go to dol.ny.gov/work-search-frequently-asked-questions to view work search activities you are required to do weekly.

5. Make a work search plan. Contact a New York State Career Center to get help planning your work search. Go to dol.ny.gov/career-centers to find the location nearest you. You may also call 800-447-3992. Choose your language and pick option 5. 6. Stop claiming benefits as soon as you return to work. Do not wait for your first paycheck. You are no longer eligible for benefits when you start working a full-time job. You may be eligible for partial benefits if you get part-time work.

7. Read your claimant handbook. It tells you about your rights and responsibilities while collecting Unemployment Insurance benefits. It also lists additional benefits and services for which you may be eligible. Electronic and audio versions are also available on our website. 8. Avoid Fraud. Do the right thing and follow the rules while you get benefits. If you do not follow the rules, you could face serious legal consequences.

9. If you don’t know, ask for help. Unemployment Insurance representatives are available to help you. Call 888-209-8124 or go to our website for answers. *To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370.

New York State Department of Labor To complete your online claim, you must also agree to the following: I have reviewed all tabbed sections and verified that the information is true and accurate, and I understand that the law provides penalties for false statements. I have provided accurate and complete contact information, including my mailing address (required) and email address (required).

If my contact information changes, I agree to update it. I agree to check and respond to secure messages and questionnaires that are sent to me through my NY.gov account and all messages, forms and letters I may receive by mail within the time frames specified in those communications. I understand that if I am not eligible for benefits, I am entitled to a hearing before an administrative law judge at no cost or obligation. If I fail to repay benefits that I received or fail to pay any penalties assessed because I withheld information or gave false information to the Department of Labor, the Department of Labor may take legal action to file a judgment against me. Once entered, a judgment is good and can be used against me for twenty years, and my money, including a portion of my paycheck and/or bank account, may be taken. Also, a judgment will hurt my credit score and can affect my ability to rent a home, find a job or take out a loan. I also confirm that I am not filing this claim during any period while I was outside of the United States, a U.S. Territory or Canada.

Secure messaging and other messages: You may send and receive secure messages, correspondence and questionnaires through your Labor Online account. Complete questionnaires and respond to correspondence by the deadline provided. Failure to do so will delay your claim or result in the denial and/or suspension of benefits.

58 Unemployment Insurance: A BRIDGE TO YOUR NEXT CAREER Unemployment Insurance: A BRIDGE TO YOUR NEXT CAREER

New York State Department of Labor

17 Forms

The following pages contain forms referenced throughout this document:

• A Work Search Record is used to record and document your work search efforts. See Chapter

7: “What is considered acceptable proof of my work search activities?”. The work search tool is located on our website at dol.ny.gov/jobzone.

• A Request for Reconsideration form may be used to notify the Telephone Claims Center* that you

disagree with information on your Monetary Benefit Determination notice.

• A Request for Alternate Base Period may be used to increase your benefit rate if your high quarter

wages are in the alternate quarter.

• A Request for Rate Based on Weeks of Employment form and instructions may be used if you think

your benefit rate may be higher using your average weekly wage.

• Voter Registration form: Do not return this form to the Department of Labor. A completed Voter

Registration form must be returned to your local Board of Elections at the address listed on the instruction page. *To reach the Telephone Claims Center, please call 888-209-8124. TTY/TDD users: call a relay operator at (800) 662-1220 and ask the operator to call 888-783-1370. Video or other types of relay service users contact your relay operator and ask the relay operator to call 888-783-1370.

1/3/2014: Attended a resume preparation workshop at the Career Center. Date of activity: Activity performed.

1/2/2014: Clerk. contact Date of: applied Position for.

1/2/2014: ABC Industries. contact Date of: Business/Employer name.

1/2/2014: HR John Director Smith,. contact Date of: Name (if contacted of known) person and title.

1/2/2014: email. contact Date of: (In email, person, of Method web contact phone, site, etc.) fax,.

1/2/2014: j.smith@abcinc.com. contact Date of: (address, method Contact email, number) website/URL, telephone of information contact number, listed fax for.

1/2/2014: Set up interview. contact Date of: response, (Interview, Result (if known) of not waiting contact hired) for.

WS (02/22) Equal Opportunity Program Auxiliary aids and services are available upon request to individuals with disabilities Attended a resume preparation workshop at the Career Center Date of activity Activity performed Other Work Search Activities: List things you did to find a job that were not business/employer contacts.

See Instructions on the back for suggested activities. The first row is an example. ABC Industries HR Director Set up interview John Smith, number) known) email, web site, etc.) email, website/URL, fax response, not hired) contact for contacted person, phone, fax, (address, telephone number, (Interview, waiting for of applied name of person of contact method of contact listed known) Date Position Business/Employer Name and title Method Contact information for Result of contact week shown above.

All columns should be filled in, to the best of your ability. Use additional sheets of paper if needed. The first row is an example. Businesses/Employers Contacted: List jobs you have applied for, interviews you have attended, and businesses/employers you have contacted during the activities per week on JobZone.

search activities for each week that you claim benefits. Please make sure the below charts show at least three separate entries or that you record three separate of this form. Simply click on the JobZone Work Search link when you claim weekly Unemployment Insurance benefits online. You must show at least three work This form may be used to record your work search activities.

Instructions are on the back. You can also use the Work Search Record on our JobZone website instead (Found at the top of appointment letters) (Last four digits only) Last Name: _________________________________ First Name______________________ NYS ID#:

Ny_______________

or SS No:

Xxx-Xx-__________

Sunday date) Work Search Record For Week Ending: _____/______/________

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Department of Labor: De.

PO Alb. Department of Labor: PO Alb. Box 15130 any, NY 12212-5130. IMPORTANT! We sent you a Monetary Benefit Determinations showing the weekly benefits you will receive. Those benefits are based on your wages. If you believe some of your wages were missed, please complete this form. This form must be received by us within 30 calendar days of the Date Mailed as stated on your most recent Monetary Benefit Determination notice. Please print clearly. If we cannot read your writing, we cannot process this form..

Unemployment Insurance Request for Reconsideration. Unemployment.

Please print clearly Last Name:___________________________________ First Name: ___________________ Middle Initial:____ Address:__________________________________________________________________________________ City:_____________________________________________ State:______________ Zip Code:____________ Claim Effective/Start Date:____/___/_____ Social Security number: XXX-XX-___ ___ ___ ___.

Form requirements To correct wages and/or add wages not reflected on your Monetary Benefit Determination, follow the instructions below. • the employer and quarterly wage information 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. • Do not send originals; photocopy all supporting documentation onto 8½ x 11 single-sided paper. • Write your name, the last four digits of your Social Security number and your phone number on each attachment. • If you received worker’s compensation, include a copy of your most recent Subsequent Report of Injury (SROI) filing. • This completed form and all attachments must be received within the time frame noted above in the IMPORTANT! message. Please print clearly..

Employer Information Please print clearly. Attach an additional page if you have information for more than (3) three employers.. Basic or Alternate Base Period Total Quarterly Gross Wages Write in the total quarterly gross wages for each employer / quarter indicated. Refer to your most recent Monetary Benefit Determination for assistance..

Employer: _________________________________ Address:__________________________________ City: _________________ State: ____ Zip:_______ If work was performed outside New York State, indicate state: _______. Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___.

Certification 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 statements. I understand I will be notified of the results of my request. __________________________________________________________ ________________ __________________________________ Signature (Required) Date Area code Telephone number.

Return instructions This notice and all attachments must be received within the time frame noted above in the IMPORTANT! message. Fax: 518-457-9378. This notice is your cover page. Indicate total number of pages ______. OR Mail: New York State Department of Labor, P.O. Box 15130, Albany, NY 12212-5130. OR Online: www.labor.ny.gov/signin. Submit via online account messaging system. Select “Submit Documents” and then “Submit Wage Documents”. Use subject line “Wage Documentation”..

Claim weekly benefits at www.labor.ny.gov or call Tel-Service at 888-581-5812.. For more information visit: www.labor.ny.gov.. F or help, see the claimant handbook at www.labor.ny.gov/uihandbook..

PO Box 15130 IMPORTANT! Albany, NY 12212-5130 We sent you a Monetary Benefit Determinations showing the weekly benefits you will receive. Those benefits are based on your wages. If you believe some of your wages were missed, please complete this form. This form must be received by us within 30 calendar days of the Date Mailed as stated on your most recent Monetary Benefit Determination notice. Please print clearly. If we cannot read your Unemployment Insurance writing, we cannot process this form.

Request for Reconsideration Please print clearly Last Name:___________________________________ First Name: ___________________ Middle Initial:____ Address:__________________________________________________________________________________ City:_____________________________________________ State:______________ Zip Code:____________ Claim Effective/Start Date:____/___/_____ Social Security number: XXX-XX-___ ___ ___ ___ Form requirements To correct wages and/or add wages not reflected on your Monetary Benefit Determination, follow the instructions below.

• the employer and quarterly wage information 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.

• Do not send originals; photocopy all supporting documentation onto 8½ x 11 single-sided paper.

• Write your name, the last four digits of your Social Security number and your phone number on each attachment.

• If you received worker’s compensation, include a copy of your most recent Subsequent Report of Injury (SROI) filing.

• This completed form and all attachments must be received within the time frame noted above in the IMPORTANT!

message. Please print clearly. Employer Information Basic or Alternate Base Period Total Quarterly Gross Wages Please print clearly. Attach an additional page if you have Write in the total quarterly gross wages for each employer / quarter indicated. Refer to information for more than (3) three employers. your most recent Monetary Benefit Determination for assistance.

Employer: _________________________________ Address:__________________________________ City: __________________State: ____ Zip:_______ If work was performed outside New York State, indicate state: _______ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Employer: _________________________________ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Address:__________________________________ City: _________________ State: ____ Zip:_______ If work was performed outside New York State, indicate state: _______ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Employer: _________________________________ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Address:__________________________________ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ City: _________________ State: ____ Zip:_______ If work was performed outside New York State, indicate state: _______ Quarter ___/___/_____ - ___/___/_____ $___ ___ ___,___ ___ ___ .___ ___ Certification 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 statements.

I understand I will be notified of the results of my request. __________________________________________________________ ________________ __________________________________ Signature (Required) Date Area code Telephone number Return instructions This notice and all attachments must be received within the time frame noted above in the IMPORTANT! message.

Fax: 518-457-9378. This notice is your cover page. Indicate total number of pages ______. OR Mail: New York State Department of Labor, P.O. Box 15130, Albany, NY 12212-5130. OR Online: www.labor.ny.gov/signin. Submit via online account messaging system. Select “Submit Documents” and then “Submit Wage Documents”. Use subject line “Wage Documentation”.

Claim weekly benefits at www.labor.ny.gov For more information visit: F or help, see the claimant handbook at or call Tel-Service at 888-581-5812. www.labor.ny.gov. www.labor.ny.gov/uihandbook.

Tc 403 Hr (09/20)

Department of Labor PO Box 15130 Albany, New York 12212-5130 www.labor.ny.gov: Please print clearly. Last Name:______________________________ First Name:___________________ Middle Initial: ______ Address:______________________________________________________________________________ City:_________________________________________ State: ___________ Zip Code:________________ Claim Effective/Start Date: ____/____/____ Social Security #: XXX – XX - __ __ __ __.

Department of Labor PO Box 15130 Albany, New York 12212-5130 www.labor.ny.gov: Form requirements. If you wish to use the Alternate Base Period to increase your weekly benefit rate: • 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 by the Response Due Date noted above. Please print clearly. If you do not, we cannot process this form. 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..

Department of Labor PO Box 15130 Albany, New York 12212-5130 www.labor.ny.gov: Step 1 Last Calendar Quarter Information. The last completed calendar quarter prior to your claim effective/start date is: ____/___/____ through ____/___/____ Month/Day/Year Month/Day/Year 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 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).

Department of Labor PO Box 15130 Albany, New York 12212-5130 www.labor.ny.gov: Step 2 Wage Information. Complete the information below, include proof of wages and attach an additional page if you have information for more than (3) three employers. Employer Name:_________________________________Quarterly Gross Wages $_________________ Employer Address: ____________________________________________________________________.

City:_________________________________State:_____________Zip:_____. If work was performed outside New York State, indicate state _______.

Employer Name:_________________________________Quarterly Gross Wages $_________________ Employer Address: ____________________________________________________________________.

City:__________________________________State:____________Zip:_____. If work was performed outside New York State, indicate state _______.

Employer Name:_________________________________Quarterly Gross Wages $__________________ Employer Address: ____________________________________________________________________.

City:__________________________________State:____________Zip:_____. If work was performed outside New York State, indicate state _______.

Department of Labor PO Box 15130 Albany, New York 12212-5130 www.labor.ny.gov: Step 3 Acknowledgement. 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 statements. I understand if I use the Alternate Base Period, these wages cannot be used for a future claim. ______________________________________________ ______________ ________ - _______ - _____________ Signature Required Date Area Code Telephone Number.

Department of Labor PO Box 15130 Albany, New York 12212-5130 www.labor.ny.gov: Step 4 Return Instructions. This notice and all attachments must be received within the time frame noted above in the IMPORTANT! message. F A X : ( 5 1 8 ) 457-9378 OR MAIL: New York State OR ONLINE: www.labor.ny.gov/signin T h i s n o t i c e i s y o u r c o v e r page. Department of Labor Submit via online account messaging Indicate total # of pages_____ PO Box 15130 system. Select “Submit Documents” and A l b a n y , New York 12212-5130 then “Submit Wage Documents”. Use subject line “Wage Documentation”..

For help, see the claimant handbook at www.labor.ny.gov/uihandbook..

Department of Labor IMPORTANT! PO Box 15130 We sent you a Monetary Benefit Determinations showing the weekly Albany, New York 12212-5130 www.labor.ny.gov benefits you will receive. Those benefits are based on your wages. If you believe some of your wages were missed, please complete this Unemployment Insurance form. This form must be received by us within 10 calendar days of the Date Mailed as stated on your most recent Monetary Benefit Request for Alternate Base Period Determination notice. Please print clearly. If we cannot read your writing, we cannot process this form.

Please print clearly Address:______________________________________________________________________________ City:_________________________________________ State: ___________ Zip Code:________________ Claim Effective/Start Date: ____/____/____ Social Security #: XXX – XX - __ __ __ __ 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 by the Response Due Date noted above. Please print

clearly. If you do not, we cannot process this form. 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 The last completed calendar quarter prior to your claim effective/start date is: ____/___/____ through ____/___/____ 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 Quarter Information 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 information Wage for more than (3) three employers.

Information Employer Address: ____________________________________________________________________ If work was performed outside New York State, indicate state _______ Employer Address: ____________________________________________________________________ If work was performed outside New York State, indicate state _______ Employer Address: ____________________________________________________________________ If work was performed outside New 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 making Acknowledgement false statements. I understand if I use the Alternate Base Period, these wages cannot be used for a future claim.

______________________________________________ ______________ ________ - _______ - _____________ 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 F A X : ( 5 1 8 ) 457-9378 OR MAIL: New York State OR ONLINE: www.labor.ny.gov/signin Instructions T h i s n o t i c e i s y o u r c o v e r page. Department of Labor Submit via online account messaging Indicate total # of pages_____ PO Box 15130 system. Select “Submit Documents” and A l b a n y , New York 12212-5130 then “Submit Wage Documents”. Use subject line “Wage Documentation”.

Claim weekly benefits at www.labor.ny.gov For more information visit: For help , see the claimant handbook at or call Tel-Service at (888) 581-5812. www.labor.ny.gov www.labor.ny.gov/uihandbook.

Tc 403 Ha (09/20)

A. Employer Name and Address: 1.. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: 2.. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: 3.. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: 4.. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: 5.. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: 6.. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: 7.. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: E. Total Weeks and Wages Worked During the Base Period. D. Total Wages Paid During Base Period: $.

A. Employer Name and Address: F. Total Weeks Worked from Part 2 (on back).

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 B. Length of Pay Period; C. Total Weeks Paid D. Total Wages Paid Address i.e. weekly, bi-weekly, During Base During Base Period etc. Period G. Recomputation Formula:

1. Divide the total wages by the total weeks (the lesser of E or F) to calculate ___________ 2. Divide the average weekly wage by 2 to arrive at your proposed rate based ___________ 3. Enter your current benefit rate from your last T402 Monetary Benefit ___________ 4. Subtract line 3 from line 2. The amount must be $5 or more to receive ___________ 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 (6/22)

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Wages: 2/2017. 1/2017. 4/2016. 3/2016.

Employer: Good Construction, Inc.. Wages: $5,000. $6,594. $7,812. $1,375. Base Period: $20,781.

Employer: Better Construction, Inc.. Wages: $640. Base Period: $640.

Employer: Best Construction, Inc.. $6,440. Base Period: $6,440.

Employer: Total. Wages: $5,640. $6,594. $7,812. $7,815. Base Period: $27,861.

www.labor.ny.gov Instructions for Request for Rate Based on Weeks of Employment Your entitlement to benefits and weekly benefit rate have been established based upon a formula using your high calendar quarter(s) earnings in your base period. Depending on your employment history, you may qualify for a higher weekly benefit based upon one-half of your average weekly wage. To request a review of your weekly benefit rate, all of the following must apply:

• Your request must be received within ten calendar days of the date of your latest Monetary Benefit Determination.

• The establishment of your base period has been finalized.

• You must have at least 20 weeks of employment in your base period. A week of work is defined as a Monday

through Sunday period during which you were paid remuneration for employment for an employer covered under the New York State Unemployment Insurance Law.

• You must provide proof of all of your base period weeks of employment and wages. Acceptable proof includes

paycheck stubs, payroll envelopes, or cancelled checks. Your proof must show name of employer, pay period/date of payment, wages and your name and/or Social Security n umber. In no event may the benefit rate calculated based on your acceptable proof be more than the maximum benefit rate currently in effect.

• The benefit rate based on one-half of your average weekly wage must be at least $5.00 more than the weekly

benefit amount based on the quarterly earnings formula as reported on your latest Monetary Benefit Determination form. The Request for Rate Based on Weeks of Employment is separate from a Request for Reconsideration. The request for Reconsideration is discussed in Section 4 of the claimant handbook: “How much will I receive in benefits each week?” A Request for Rate Based on Weeks of Employment cannot be made until you finalize the base period to utilize and a determination has been issued on any Request for Reconsideration.

On the reverse side is an example of a completed Request for Rate Based on Weeks of Employment form. The example assumes a benefit claim filed in the 4th quarter 2017 and wages employers reported to the New York State Wage Reporting system within the basic base period July 1, 2016 through June 30, 2017.

Employer Wages Base Period 2/2017 1/2017 4/2016 3/2016 Good Construction, Inc. $5,000 $6,594 $7,812 $1,375 $20,781 Better Construction, Inc. $640 $640 Best Construction, Inc. $6,440 $6,440 Total $5,640 $6,594 $7,812 $7,815 $27,861 The rate based on one twenty-six (1/26) of the high quarter wages is $300. For those with $3,575 or less wages in the high quarter, the weekly benefit rate is based on one twenty-fifth (1/25).

The rate based on weekly employment and wages data as evidenced by acceptable proof is $309. (See calculations on page 2 of the instructions.)

A. Employer Name and Address: 1. Good Construction, Inc. Anytown, NY 10101. B. Length of Pay Period; i.e. weekly, bi-weekly, etc.: Bi-weekly. C. Total Weeks Paid During Base Period: 43. D. Total Wages Paid During Base Period: $. 20,781.

A. Employer Name and Address: 2. Better Construction, Inc. Anytown, NY 10101. B. Length of Pay Period; i.e. weekly, bi-weekly, etc.: Bi-weekly. C. Total Weeks Paid During Base Period: 2. D. Total Wages Paid During Base Period: $. 640.

A. Employer Name and Address: 3. Best Construction, Inc. Anytown, NY 10101. B. Length of Pay Period; i.e. weekly, bi-weekly, etc.: Weekly. C. Total Weeks Paid During Base Period: 8. D. Total Wages Paid During Base Period: $. 6,440.

A. Employer Name and Address: 4..

A. Employer Name and Address: 5..

A. Employer Name and Address: 6..

A. Employer Name and Address: 7..

A. Employer Name and Address: E. Total weeks and wages worked during the base period. C. Total Weeks Paid During Base Period: 53. D. Total Wages Paid During Base Period: $. 27,861.

A. Employer Name and Address: F. Total weeks worked from Part 2. C. Total Weeks Paid During Base Period: 45.

Weeks →→ Employer ↓↓: A. 61/42/7: . 61/13/7: . 61/70/8: . 61/41/8: . 61/12/8: . 61/82/8: . 71/20/4: . 71/90/4: . 71/61/4: . 71/32/4: . 71/41/5: . 71/12/5: . 71/82/5: . 71/40/6: . 71/11/6: . 71/81/6: . 71/52/6: .

Weeks →→ Employer ↓↓: B. 71/40/6: . 71/11/6: .

Weeks →→ Employer ↓↓: C. 61/30/7: . 61/01/7: . 61/42/7: . 61/13/7: . 61/70/8: . 61/41/8: . 61/12/8: . 61/82/8: .

Weeks →→ Employer ↓↓: Etc..

Key:: X. = No work available. Gross Weeks: Concurrent Weeks. 53: 8.

Key:: *. = Weeks 10-39; worded 26 weeks for “A”. Gross Weeks: Net Weeks. 53: 45.

on the back of the Request for Rate Based on Weeks of Employment form. In the example below, the total weeks on line F are less than the sum of the weeks as shown on line E due to concurrent employment in the base period. Example – Request for Rate Based on Weeks of Employment 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. Good Construction, Inc. Bi-weekly 43 $ 20,781 Anytown, NY 10101 Anytown, NY 10101 3. Best Construction, Inc. Weekly 8 $ 6,440 Anytown, NY 10101 G. Recomputation Formula Example 1. Divide the total wages by the total weeks (the lesser of line E or F) to calculate 2. Divide the average weekly wage by 2 to arrive at your proposed rate based on 3. Enter your current benefit rate from your last T402 Monetary Benefit 4. Subtract line 3 from line 2. The amount must be $5 or more to receive Example Weeks →→ Employer ↓↓ 61/30/7 61/01/7 61/71/7 61/42/7 61/13/7 61/70/8 61/41/8 61/12/8 61/82/8 71/20/4 71/90/4 71/61/4 71/32/4 71/03/4 71/70/5 71/41/5 71/12/5 71/82/5 71/40/6 71/11/6 71/81/6 71/52/6

A                 

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Unemployment Insurance Division PO Box 15131 Albany, NY 12212-5131 Claimant Request for Hearing Enter the last four digits of your Social Security Number (SSN): _____ _____ _____ _____ Your Name (print): You can request an Unemployment Insurance (UI) hearing two ways, online or by mail.

• To request a hearing online, sign into your NY.Gov account. Click on the envelope icon at the upper right of your

My Online Services page. Then create a new email message. Choose “Hearings and Appeals” from the drop- down menu as the first subject line and “I want to request a hearing” as the second subject line.

• To request a hearing by mail, complete and sign this form. Mail it to the address at the top of this form. Write

only in the space provided on this form. Do not write outside the margins or on the back. If you need more space, use an 8 ½ x 11-inch piece of white paper. Be sure to write your name and the last four digits of your Social Security number on all of the papers you send. Do not staple. IMPORTANT: To protect your rights to UI benefits you may be entitled to receive, please continue to certify for UI benefits every week, as long as you are unemployed.

I disagree with the Notice of Determination(s) dated ____/____/_______ (month, day, year), and I am requesting a hearing. Reason (optional): If you are requesting a hearing on a determination that was made more than 30 days ago, please state the reason for the delay in notifying us: Last Employer’s Name:

Physical work location (place where you regularly reported to work): Street City State Zip Code Work Phone Number: ( ) Would you like your hearing conducted in a language other than English? Yes No

If yes, what language and dialect?

Dates you are unavailable for a hearing: Email: Phone: ( ) Mailing Address: Apt/Floor: City: State: Zip: Signature Date For information about the UI Claimant Advocate Office and to view a video on how to prepare for a hearing, visit our website at dol.ny.gov/unemployment-insurance-claimant-advocate-office.

Lo 435 (06/22)

Address and stamp this section Your address Place First-Class Stamp Here Instructions for Voter Registration Form 1. Fill out the Voter Registration form that immediately follows this instruction sheet. 2. Carefully tear it out of this booklet and put it in an envelope. Be sure to include your return address and correct postage.

Your County Board of Elections address (select from below) 3. Mail to the County Board of Elections in the county in which you live (see list at bottom of this page). Do not mail this form to the Department of Labor! We cannot process it and will have to return it to you. This will delay your registration.

Before mailing, remove tape, fold and seal New York City Chenango Franklin Lewis Oneida Putnam Schuyler Ulster 32 Broadway, 7th Fl. 5 Court St. 355 West Main St. 7660 N. State St. Union Station 25 Old Route 6 County Office Bldg. 284 Wall St. New York, NY 10004 Norwich, NY 13815 Ste. 161 Lowville, NY 13367 321 Main St. Carmel, NY 10512 105 9th St., Unit 13 Kingston, NY 12401 (212) 487-5300 (607) 337-1760 Malone, NY 12953 (315) 376-5329 3rd Fl. (845) 808-1300 Watkins Glen, NY (845) 334-5470 (518) 481-1663 Utica, NY 13501 14891 Clinton Livingston (315) 798-5765 Rensselaer (607) 535-8195 Warren Albany Cnty Government Ctr. Fulton County Govt. Ctr. Ned Pattison Cnty. Municipal Ctr.

260 S. Pearl St. Ste. 104 2714 St. Hwy 29 6 Court St. Onondaga Government Ctr. Seneca 3rd Floor Albany, NY 12202 137 Margaret St. Ste. 1 Room 104 1000 Erie Blvd West 1600 Seventh Ave. One DiPronio Dr. Human Serv. Bldg (518) 565-4740 (518) 736-5526 (585) 243-7090 (315) 435-3312 (518) 270-2990 (315) 539-1760 Lake George, NY Allegany 12845 8 Willets Ave. Columbia Genesee Madison Ontario Rockland Steuben (518) 761-6456 Belmont, NY 14813 401 State St. County Building #1 County Office Bldg. 74 Ontario St. 11 New Hempstead Rd. 3 E. Pulteney Sq.

(585) 268-9294 Hudson, NY 12534 15 Main St. N. Court St. Canandaigua, NY New City, NY 10956 Bath, NY 14810 Washington (518) 828-3115 Batavia, NY 14020 PO Box 666 14424 (845) 638-5172 (607) 664-2260 383 Broadway Broome (585) 815-7804 Wampsville, NY (585) 396-4005 Fort Edward, NY Government Plaza Cortland 13163 St. Lawrence Suffolk 12828 60 Hawley St. 112 River St. Greene (315) 366-2231 Orange 80 State Hwy 310 Yaphank Ave. (518) 746-2180 Binghamton, NY Cortland, NY 13045 Ste. 437 Monroe PO Box 30 (315) 379-2202 Yaphank, NY 11980 Wayne Delaware (585) 753-1550 50 W. High St. Sullivan Lyons, NY 14489 Cattaraugus 3 Gallant Ave. Hamilton Orleans Ballston Spa, NY Gov’t. Ctr. (315) 946-7400 207 Rock City St. Delhi, NY 13753 Rte. 8 Montgomery 14016 Route 31 West, 12020 100 North St.

Suite 100 (607) 832-5321 PO Box 175 Old Courthouse Ste. 140 (518) 885-2249 PO Box 5012 Westchester C ( L 7 i a t 1 t y 6 le u ) V 9 g a 3 a l 8 le - y 2 , 4 N 0 Y 0 14755 1 S P D 1 u o u 2 i u t t e g D c h 2 h e k 0 l e a e 0 s f e i s e p ld s i S e, t r N ee Y t , 1 ( L 5 2 a 1 1 k 8 0 e ) 8 P 5 l 4 e 8 as -4 a 6 nt 8 , 4 N Y ( P F 9 5 o O P 1 n 8 a B d r ) k a o 8 , x S 5 N t 1 3 . Y 5 -8 0 1 1 0 2 8 0 0 6 8 A O (5 l s b 8 w i 5 o ) e n 5 , g 8 N o 9 Y - 3 1 2 4 7 4 4 1 1 2 S S 6 c c h 9 h e 6 e n n H e e a c c m ta t b a d u d y r , y g N S Y t . T ( M 8 io 4 o 5 g n ) t a i 8 c e 0 l 7 lo -0 , N 40 Y 0 1 2701 1 2 ( W 9 0 5 1 6 h Q 4 i 0 t ) u e 1 9 a P 9 rr l 5 a o - i p n 5 a s 7 s , 0 N S 0 Y t .

(Basement) (845) 486-2473 109 Mary St. Nassau Box 9 (518) 377-2469 PO Box 306 Wyoming Auburn, NY 13021 Ste. 1306 240 Old Country Rd. Oswego, NY 13126 Owego, NY 13827 4 Perry Ave. (315) 253-1285 Erie Herkimer, NY 13350 5th Fl. (315) 349-8350 Schoharie (607) 687-8261 Warsaw, NY 14569 134 W. Eagle St. (315) 867-1102 PO Box 9002 County Office Bldg. (585) 786-8931 Chautauqua Buffalo, NY 14202 Mineola, NY 11501 Otsego 284 Main St. Tompkins 7 North Erie St. (716) 858-8891 Jefferson (516) 571-8683 Ste. 2 PO Box 99 Court House Annex Yates Mayville, NY 14757 175 Arsenal St. 140 County Hwy. 33W Schoharie, NY 12157 128 E. Buffalo St. Ste. 1124 (716) 753-4580 Essex Watertown, NY 13601 Niagara Cooperstown, NY (518) 295-8388 Ithaca, NY 14850 417 Liberty St.

7551 Court St. (315) 785-3027 111 Main St. 13326 (607) 274-5522 Penn Yan, NY 14527 Chemung PO Box 217 Ste. 100 (607) 547-4247 (315) 536-5135 378 South Main St. Elizabethtown, NY Lockport, NY 14094 PO Box 588 12932 (716) 438-4040 Elmira, NY 14902 (518) 873-3474 (607) 737-5475 (Optional) Register to donate your organs and tissues If you would like to be an organ and tissue donor upon your death, You will receive a confirmation email or letter, which will also provide you may enroll in the NYS Donate Life™ Registry online at you an opportunity to limit your donation.

www.donatelife.ny.gov or complete the form below. Last name By signing below, you certify that you are: First name

• 16 years of age or older;

• consenting to donate all of your organs and

Suffix Middle Initial tissues for transplantation, research, or both;

• authorizing the Board of Elections to provide

Address your name and identifying information to NYS Donate Life™ Registry for enrollment; Zip code Apt.Nu mber • and authorizing the Registry to give access to this information to federally regulated organ City procurement organizations and NYS-licensed M M D D Y Y Y Y tissue and eye banks and others approved by the Birth date / / Gender M F NYS Commissioner of Health upon your death.

Eye color Height Ft. In. Email DMV or ID NYC # Sign Date

1. Are you a U.S. citizen? YES NO If you answered NO, do not complete this form. 2. A) Will you be 18 years old on or before election day? YES NO B) Are you at least 16 years of age and understand that you must be 18 y ears of age on or before election day to vote, and that until you will be eighteen years of age at the time of such election your registration will be marked “pending” and you will be unable to cast a ballot in any election? YES NO If you answered NO to both of the prior questions, you cannot register to vote.. For Board Use Only.

3. Last Name First Name Middle Initial Suffix.

4. Address where you live (do not give P.O. box) Apt. No. City/Town/Village Zip Code County.

5. Address where you get your mail (if different than above) P.O. Box, Star Route, etc. Post Office Zip Code.

6. Date of Birth. 7. Gender (optional). 8. Telephone (optional). Email (optional).

10. The last year you voted. Your address was (give house number, street and city). 9. ID Number (Check the applicable box and provide your number) New York State DMV number Last four digits of your Social Security number I do not have a New York State DMV or Social Security number.

In county/state. Under the name (if different from your name now).

11. Political Party I wish to enroll in a political party Democratic party Libertarian party Republican party Independence party Conservative party SAM party Working Families party Other Green party I do not wish to enroll in any political party and wish to be an independent voter No party. 12. Affidavit: I swear or affirm that • I am a citizen of the United States. • I will have lived in the county, city or village for at least 30 days before the election. • I will meet all requirements to register to vote in New York State. • This is my signature or mark on the line below. • The above information is true, I understand that if it is not true, I can be convicted and fined up to $5,000 and/or jailed for up to four years. / / Signature or Mark in ink Date.

Last Name: First Name. Middle Initial. Suffix.

Last Name: Address.

Last Name: Apt Number. City/Town/Village. Zip Code.

Last Name: Birth Date. Gender M F.

Last Name: Eye Color. Height Ft. In..

Last Name: Email. DMV or ID NYC Number.

NYS Agency-Based Voter Registration Form “If you are not registered to vote where you live now, would you Important! like to apply to register here today?” Applying to register or declining to register to vote will not affect the YES If you checked YES, please complete the If a y n o y u b d o o x , n y o o t u c h w e i c ll k amount of assistance that you will be provided by this agency.

VOTER REGISTRATION APPLICATION below be considered to If you would like help filling out the voter registration application form, NO because I choose not to register OR have decided not we will help you. The decision whether to seek or accept help is yours. to register to vote You may fill out the application form in private.

I am already registered at my current address OR at this time. I asked for and received a mail registration form Información en español: si le interesa obtener este formulario en español, llame al 1-800-367-8683 / / 中文資料:若您有興趣索取中文資料表格,請電: 1-800-367-8683 Signature Date 한국어: 한국어 한국어 양식을 원하시면 1-800-367-8683 으로 전화 하십시오.

যদিআ পদিএ ইফ রটি্মই ংরেজীরেপ পরেচ ািে াহরে1 -800-367-8683 Please Print Name িম্বরে পফাি করুি VOTER REGISTRATION APPLICATION (instructions on back) Yes, I need an application for an Absentee Ballot Please print or type in blue or black ink Yes, I would like to be an Election Day worker Are you a U.S. citizen? For Board Use Only

1 Yes No 2

y b e e a e r i s g o h f t e a e g n e y o e n a o r r s b o e f f a o g r e e a e t l e t c h t e i o ti n m d e a o y f t o su v c o h t e e l e a c n t d i o th n a y t o u u n r t r i e l g yo is u t r w at il i l o n will be marked “pending” and you will be unable to cast a ballot in any If you answered NO, do not complete this form election? YES NO If you answered NO to both of the prior questions, you cannot register to vote.

Date of Birth Gender (optional) Telephone (optional) Email (optional) 6 7 8 The last year you voted Your address was (give house number, street and city) ID Number (Check the applicable box and provide your number) New York State DMV number In county/state Under the name (if different from your name now) Last four digits of your Social Security number I do not have a New York State DMV or Social Security number Political Party Affidavit: I swear or affirm that I wish to enroll in a political party • I am a citizen of the United States.

• I will have lived in the county, city or village for at least 30 days before

Democratic party Libertarian party the election. Republican party Independence party

• I will meet all requirements to register to vote in New York State.

11 Conservative party SAM party 12 • This is my signature or mark on the line below. Working Families party Other

• The above information is true, I understand that if it is not true, I can be

Green party convicted and fined up to $5,000 and/or jailed for up to four years. I do not wish to enroll in any political party and wish to be an independent voter / / No party Signature or Mark in ink Date (Optional) Register to donate your organs and tissues Last Name By signing below, you certify that you are:

• 16 years of age or older

First Name Middle Initial Suffix

• Consent to donate all of your organs and tissues for

transplantation, research, or both; Address • Authorizing the Board of Elections to provide your name and identifying information to NYS Donate Life Registry for enrollment; Apt Number City/Town/Village Zip Code • And authorizing the Registry to allow access to this information to federally regulated organ procurement organizations and NYS-licensed tissue and eye banks and others approved by the NYS Commissioner of Health hospitals upon your death.

Birth Date Gender M F Eye Color Height / / Ft. In. Signature Date Email DMV or ID NYC Number

Qualifications for Registration Important! You Can Use This Form To: If you believe that someone has interfered with your right to register or

• register to vote in New York State; to decline to register to vote, your right to privacy in deciding whether to

• change your name and/or address, if there is a change since you register or in applying to register to vote, or your right to choose your own

last voted; political party or other political preference, you may file a complaint with:

• enroll in a political party or change your enrollment;

NYS Board of Elections

• pre-register to vote if you are 16 or 17 years of age.

To Register You Must: Albany, NY 12207-2729

• be a U.S. citizen; Telephone: 1-800-469-6872;

• be 18 years old (you may pre-register at 16 or 17 but cannot vote until you TDD/TTY users contact the New York State Relay at 711;

are 18); or visit our web site - www.elections.ny.gov

• be a resident of the County, or of the City of New York at least 30 days

before an election; Your decision to register will remain confidential and will be used only for

• not be in prison or on parole for a felony conviction (unless parole pardoned voter registration purposes. Anyone not choosing to register to vote and/

or restored rights of citizenship); or information regarding the office to which the application was submitted

• not claim the right to vote elsewhere; and will remain confidential, to be used only for voter registration purposes.

• not found to be incompetent by a court.

Verifying your identity We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID number), or the last four digits of your social security number, which you will fill in Box 9. If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement, paycheck, government check or some other government document that shows your name and address. You may include a copy of one of those types of ID with this form.

If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time. To complete this form: It is a crime to procure a false registration or to furnish false information to the Board of Elections. Box 9: You must make one selection. For questions refer to Verifying your identity above.

Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?). If you voted before under a different name, put down that name. If not, write “Same”. Box 11: Check one box only. Political party enrollment is optional but that, in order to vote in a primary election of a political party, a voter must enroll in that political party, unless state party rules allow otherwise.

EQUAL

Opportunity

Is The Law

It is against the law for all recipients of Federal financial assistance to discriminate on the following basis: Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Innovation and Opportunity Act (WIOA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIOA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following areas: Deciding who will be admitted, or have access, to any WIOA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to such a program or activity; or making employment decisions in the administration of, or in connection with such a program or activity.

What to Do If You Believe You Have Experienced Discrimination If you think you have been subjected to discrimination under a WIOA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: Director Or you may file a complaint Division of Equal Opportunity Development directly with:

New York State Department of Labor Director Civil Rights Center (CRC) Albany, New York 12226 U.S. Department of Labor PHONE: 518-457-1984 200 Constitution Avenue, NW (TDD) 1-800-662-1220 Room N-4123 (VOICE) 1-800-421-1220 Washington, D.C. 20210 If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC.

However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.

The New York State Department of Labor is an Equal Opportunity Employer/Program. DEOD 310.1 (1/24) Auxiliary aides and services are available upon request and free of charge to individuals with disabilities TTY/TDD 711 or 1-800-662-1220 (English) / 1-877-662-4886.

unemployment insurance claimant handbook tc318.3 (Part 4 of 4)

14 Appendix Ii: Sending A Secure

Message

15 Appendix Iii: Online Filing Terms

And Conditions

17 Forms

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1 Yes No 2

Opportunity

Is The Law

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