Pandemic Unemployment Insurance
Request for Reconsideration
Last name: First name: Middle initial:
Address:
City: State: Zip code:
Social Security Number (Required):
Form requirements
To correct earnings and/or add earnings not reflected on your Monetary Benefit Determination, follow the
instructions below.
• Complete the chart below and return with any documentation that could be proof of earnings such as
pay stubs, W-2s, 1099s, or if you are self-employed, proof of your annual net income for the most
recently filed tax year.
• Do not send originals of your supporting documents as they cannot be returned.
• Photocopy all supporting documentation onto 8 ½ by 11 single-sided paper.
• Write your name, Social Security Number, and your phone number on each page of the attachment.
You may submit by:
Fax to: 518-457-9378 or,
Mail to: New York State Department of Labor, PO Box 15130, Albany, NY 12212-5130
Total amount of earnings:
Certification
I certify that the above information is true to the best of my knowledge and 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
PUA10R (11/20)
