tegl14-11a1.pdf

ETA Advisory File Text

U.S. Department of Labor Employment and Training Administration OMB No. 1205-0342 Expires 1 31 2013 Petition for Trade Adjustment Assistance TAA Page 1 of 3 ETA-9042 Rev. October 2011 Previous forms not usable Ab out the Trade Adjustment Assistance TAA Program The Trade Act of 1974 19 USC 2271 et seq. as amended established Trade Adjustment Assistance TAA to provide assistance to workers in firms hurt by foreign trade. Program benefits include long-term training while receiving income support. TAA provides both rapid and early assistance. Filing this petition is the first step in qualifying for benefits and assistance. After the petition is filed the U.S. Department of Labor will determine whether a significant number or proportion of the workers of the firm have become total or partially separated or are threatened to become totally or partially separated and whether imports or a shift in production or services to a foreign country contributed importantly to these actual or threatened separations and to a decline in sales or in production of articles or supply of services. If a petition is approved and the workers are certified as eligible to participate in the TAA program workers covered by a certification may contact their state workforce agency to apply for benefits. These benefits are provided at no expense to employers. Filing Instructions A group of three workers from the same firm a union official a state or local workforce agency representative in a local One Stop Career Center an employer official or a legally authorized representative must complete this Petition Form by answering all questions before submitting to the U.S. Department of Labor. You must date and submit the Petition Form within 1 YEAR from the date on which the workers were separated or had their hours and wages reduced. You must file the Petition Form with both the U.S. Department of Labor in Washington DC and the TAA Coordinator or the dislocated worker office of the state where the firm is located. To file with the U.S. Department of Labor use one of the methods below Fax the completed Petition Form to 202-693-3585 OR Mail the completed Petition Form to the U.S. Department of Labor at U.S. Department of Labor Office of Trade Adjustment Assistance 200 Constitution Ave NW Room N-5428 Washington DC 20210 To file with the TAA Coordinator or the State Dislocated Worker Unit or State Workforce Agency Use the contact information below to find the appropriate filing address. If this Petition Form includes firms in different states copies of this completed Petition Form must be filed in each state where firms are located. Toll-Free Helpline 1-877-US2-JOBS TTY 1-877-889-5627 Internet http www.doleta.gov tradeact contacts.cfm State or http www.servicelocator.org For assistance in preparing a petition Petitioners may request assistance in preparing the petition at their local One-Stop Career Center by contacting the U.S. Department of Labor in Washington D.C. at 202-693-3560 Main Number or by contacting their State Dislocated Worker Unit or State Workforce Agency through the telephone numbers or internet addresses provided above. To check petition status To check the status of your petition please visit http www.doleta.gov tradeact Public Burden Statement 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. Responding is required to obtain or maintain benefits 19 USC 2321 . 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 completing and reviewing the collection of information and a state review. 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 above Paperwork Reduction Project 1205-0342 . 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 1 31 2013 Petition for Trade Adjustment Assistance TAA Page 2 of 3 For more information visit our Web site at http www.doleta.gov tradeact ETA-9042 Rev. October 2011 Previous forms not usable Section 1. Petitioner Information Provide petitioner information below. Three workers from the same job location completing this Petition Form must fill in all three columns. Other petitioners need only fill in the Petitioner 1 column. A union official completing this petition form should provide the name of the Union. Petitioner 1 Petitioner 2 Petitioner 3 a Name b Title c Street Address City State Zip d Phone Main e Phone Alternate f E-mail g Worker Separation Date h Petitioner Type Three Workers Company Official Union Official Union Name please check one State Workforce Office One -Stop Operator Partner Other Authorized Represent ative i Describe the worker group on whose behalf this petition is being filed Section 2. Workers Firm Provide information on the firm employing the worker group. Complete items a g regarding the employing firm. If the workers are doing work at a location that is different than the worker s employer e.g. the petitioning workers are employed by a staffing agency but work at a manufacturing firm also complete items h m regarding the firm at which the workers perform their jobs. NOTE Workers completing this Petition Form must provide information for the location where they work. All other petitioner types may apply on behalf of more than one location. State offices and One-Stop Operators Partners may file for workers at multiple locations of a firm within their State. If you choose to file on behalf of workers at more than one location please attach additional sheets as necessary. Employer Firm a Name of Firm b Street Address City State Zip c Ph one d Website if known e Describe the article produced or service supplied by this firm f How many workers have been or may be separated if known g Is the firm or any part of the firm closing if known If yes when If the work ers work at a location that is different from that listed in item a and b then fill out items h through m for that locat ion h Name of Firm i Street Address City State Zip j Phone k Describe the article produced or se rvice supplied by this firm l How many workers have been or may be separated if known m Is the firm or any part of the firm closing if known If yes when U.S. Department of Labor Employment and Training Administration OMB No. 1205-0342 Expires 1 31 2013 Petition for Trade Adjustment Assistance TAA Page 3 of 3 For more information visit our Web site at http www.doleta.gov tradeact ETA-9042 Rev. October 2011 Previous forms not usable Section 3. Trade Effects on Separations 1. To the best of your knowledge provide reasons why you believe that separations that have occurred or may be threatened at the workers firm are due to foreign trade. Example Production has been is being shifted to a foreign country services are being outsourced to a foreign country increased imports of articles or services loss of business with a TAA-certified firm. 2. If you possess any additional information or documents that you believe may assist in the determination of whether the worker group is eligible for TAA benefits submit it as an attachment to the Petition Form. Check the box below if you have attached any additional information or supporting documents. I have attached additional information or supporting documents. 3. Provide contact information for two company officials. Either separately or together these officials should be familiar with all of the following employment job functions and sales or production at each job location. Official 1 Official 2 a Name b Title c Pho ne Main d Phone Alternate e Fax f E-mail 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 . For this petition to be valid each of the petitioners listed in Question 1 must sign below and the Petition Form must be dated. By signing below you agree to the following statements I declare that to the best of my knowledge and belief the information I have provided is true correct and complete. a Signature b Name Print c Date of Petition