Free TAA Petition Form - Tennessee

U.S. Department of Labor

Employment and Training Administration

OMB No. 1205-0342 Expires: 2/28/2009

Instructions for Completing the Petition for Trade Adjustment Assistance (TAA) and Alternative Trade Adjustment Assistance (ATAA)
Instructions The Trade Act of 1974 (19 USC § 2271 et seq.), as amended, established Trade Adjustment Assistance (TAA) to provide assistance to workers in companies affected by imports from foreign countries, shifts in production to certain foreign countries, and to certain secondary workers. The program provides affected workers with both rapid and early assistance and the opportunity to engage in long-term training while receiving income support. These benefits are provided at no expense to employers. Alternative Trade Adjustment Assistance (ATAA) for older workers is an alternative to TAA for trade affected workers 50 years of age or older. ATAA encourages qualified trade affected workers to quickly obtain full-time employment by providing a wage subsidy in lieu of training and income support. Submission of a completed Petition Form signifies a desire to file for both TAA and ATAA. If certified for both programs, workers will have the option of applying for TAA benefits and services and, if reemployment occurs within 26 weeks of the worker's separation, may be eligible to receive ATAA instead of TAA, if the worker desires. A worker group (minimum of three workers), union official or other authorized representative, state or local agency representative in a local One Stop Career Center, or knowledgeable firm official must complete this Petition Form, by answering all questions before submitting it to the Department. Persons are not required to respond to this collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. Public reporting burden for this collection is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Department of Labor at the address provided below (Paperwork Reduction Project 1205-0342). Filing Directions You must date and submit the Petition Form within 1 YEAR from the date on which the workers were separated or had their hours/wages reduced, but no more than 60 days before layoffs are scheduled or expected to begin. You must file the Petition Form with both the Department of Labor in Washington, DC and the TAA coordinator or the dislocated worker office of the state where the firm/subdivision is located. o To file with the Department of Labor, use one of the methods below (electronically submit or fax for quicker processing): Electronically submit the Petition Form online at http://www.doleta.gov/tradeact/petitions.cfm OR Fax the completed Petition Form to 202-693-3584 or 202-693-3585, OR Mail the completed Petition Form to the Department of Labor address provided below. o To file with the TAA coordinator or the dislocated worker office of the state: Use the contact information below to find the appropriate filing address. If this petition includes firms/subdivisions in different states, copies of this completed Petition Form must be filed in each state where firms/subdivisions are located. Toll-Free Helpline: Internet: Questions? Contact the Department of Labor at: U.S. Department of Labor Division of Trade Adjustment Assistance Room C-5311 200 Constitution Ave., N.W. Washington, DC 20210 Petition Form Page 1 of 3 1-877-US2-JOBS (TTY) 1-877-889-5627 http://www.servicelocator.org

Phone Fax Internet

202-693-3560 202-693-3584, 3585 http://www.doleta.gov/tradeact ETA-9042a (Rev. 11/05)

For more information, visit our Web site at http://www.doleta.gov/tradeact

U.S. Department of Labor

Employment and Training Administration

OMB No. 1205-0342 Expires: 2/28/2009

Petition for Trade Adjustment Assistance (TAA) and Alternative Trade Adjustment Assistance (ATAA)
Information in all sections should be printed or typed.

Section 1. Petitioner Information
1. Provide petitioner information below. Workers completing this Petition Form must fill in all three columns. Other petitioners must fill in at least the Petitioner 1 column.
Petitioner 1 a) b) c) Name Title Street Address Petitioner 2 Petitioner 3

City State, Zip d) Phone ­ Main e) Phone­ Alternate f) Email g) Worker Separation Date h) Petitioner Type: Three Workers (please check one) State Workforce Office

Company Official One-Stop Operator/Partner

Union Official Other Authorized Representative

Section 2. Workers' Firm/Subdivision Information
2. Provide information on the firm or appropriate subdivision employing the worker group. Workers completing this petition should provide information for the subdivision/location where they work. All other petitioner types may apply on behalf of more than one subdivision; if you choose to do so, attach additional sheets as necessary.
Name of Firm/Subdivision Street Address City State, Zip Phone Website (if appropriate) Federal Employer Identification Number (If known) What (if any) articles are produced at subject firm? If none are produced, what do workers do? How many workers have been or will be laid off? Is the plant closing?

a) b)

c) d) e) f) g) h)

If yes, when?

3.
a) b) c) d) e)

Provide contact information for two knowledgeable officials familiar with the trade effects at each firm/subdivision.
Firm/Subdivision Official 1 Name Title Phone ­ Work Phone ­ Alternate Fax Email Firm/Subdivision Official 2 (if known)

4.
a) b)

Is the worker group (check the boxes that apply):
Employed by a firm/subdivision that produces an article(s) Contracted to perform work for a firm/subdivision that produces an article(s)

Petition Form

Page 2 of 3

ETA-9042A (Rev. 11/05)

For more information, visit our Web site at http://www.doleta.gov/tradeact

U.S. Department of Labor

Petition for TAA and ATAA

Section 3. Trade Effects
5.
a)

In your opinion, does the worker group work at a firm or subdivision that has: (check appropriate box(es) below)
Increased imports of like or directly competitive article(s) from a foreign country(s) Shifted production of the article(s) to a foreign country(s) Customers that have increased imports from a foreign country(s) Supplied component parts for articles produced by a firm with a currently TAA certified worker group Assembled or finished articles provided by a firm with a currently TAA certified worker group

b) c)

6.
a) b)

If you checked Question 5(b) or 5(c) above, provide the following information for the firm with a currently TAA certified worker group:
Firm Name Street Address City State, Zip Phone Article(s) Produced Certification Number and Date (If known)

c) d) e)

7.

Provide the reasons why you believe the worker group is eligible for TAA and ATAA certification, in the space below. Submit any available information or evidence that shows that the worker group is eligible as an attachment to the petition form.

8.

Check the box below if you have attached any additional information or supporting documents.
I have attached additional information or supporting documents.

Section 4. Affirmation of Information
The information you provide on this petition form will be used for the purposes of determining worker group eligibility and providing notice to petitioners, workers, and the general public that the petition has been filed and whether the worker group is eligible. Knowingly falsifying any information on this Petition Form is a Federal offense (18 USC § 1001) and a violation of the Trade Act (19 USC § 2316). Each of the petitioners listed in Question 1 must sign below and the petition must be dated in order to be valid. By signing below, you agree to the following statement:

"Under penalty of law, I declare that to the best of my knowledge and belief the information I have provided is true, correct, and complete."
a) b) c) Signature Name (Print) Date of Petition

The petition will be made available for public inspection and copying under the Freedom of Information Act, as amended (5 USC § 552), Executive Order 12600, and 29 CFR Part 70, upon written request to the Department of Labor.

Petition Form

Page 3 of 3

ETA-9042A (Rev. 11/05)

For more information, visit our Web site at http://www.doleta.gov/tradeact