ETA 9043a Business Confidential Data Request

Business Confidential Data Request Compliance Date:

U.S. Department of Labor Division of Trade Adjustment Assistance

OMB No. 1205-0342 Expires:

A petition for Trade Adjustment Assistance (TAA) and Alternative Trade Adjustment Assistance (ATAA) has been filed on behalf of a group of workers employed (or formerly employed) by your firm. Your assistance in expeditiously completing the Business Confidential Data Request is necessary for the U.S. Department of Labor to determine whether these workers may be eligible for federal benefits. By law, this determination must be made within 40 days of the petition filing date (19 U.S.C. 2273(a)). Accordingly, please complete and return this form no later than [Insert date here].

Background – 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.

How this information will be used – The U.S. Department of Labor will use the information you provide on this form to determine whether the group of workers meet the certification criteria established by law for eligibility to apply for TAA and ATAA.

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 mandatory (19 USC 2321). Public reporting burden for this collection is estimated to average 3.5 hours 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 U.S. Department of Labor, Division of Trade Adjustment Assistance, Room N-5428, 200 Constitution Ave., N.W., Washington, DC 20210 (Paperwork Reduction Project 1205-0342).

Confidentiality - All information submitted under this request will be used only to determine whether the criteria for certification of the workers covered by the petition have been satisfied. The U.S. Department of Labor will protect the confidentiality of the information you provide to the full extent of the law.

Instructions - Type or print legibly. Complete all sections. Attach additional sheets if necessary. If there is no quantity or value, enter “zero” or “none”. On a separate sheet, please add any relevant information not covered in this form that you would like the U.S. Department of Labor to consider, and attach any supporting documents. If you have any difficulty completing this form or have questions, please contact [Insert Investigator name and contact information].

TA-W - :	[     ]
Subject Firm:	[     ]
Location:	[     ]

Subject Firm Information:

Official Subject Firm Name

Division

Address

Website (if appropriate)

Parent company of subject firm

Address

Affiliates, branches, and subdivisions producing like or directly competitive products

Federal Employer Identification No. (FEIN)

In the past one year, have the workers wages been reported under another FEIN?

Yes

No

If workers’ wages at the subject firm were reported under another FEIN, please explain why and specify the number and the corporate name:

Leased Workers: Identify all contract entities and staffing agencies supplying leased or temporary workers to the subject firm since [Insert Impact Date] and describe their functions

Organizational Structure: Describe the organizational structure of the subject firm, including, but not limited to, the parent company, affiliates, subsidiaries, and subdivisions. (Please attach any existing diagrams of organizational structure)

4. Articles produced: Identify the articles (products) manufactured at the subject firm. Include the North American Industry Classification System (NAICS) code(s) for the subject plant, division or subdivision, and the Harmonized Tariff Schedule classification for the articles produced there, if known:

5. Recent Activities of Subject Firm: (Check Yes, No, or Unknown in the space provided)

How many workers were separated at the subject firm since [Insert Impact Date]?

If future worker separations are planned or expected, when will they occur? __________________________________

How many workers will be separated? ___________________________________________

Yes

No

Unknown

Has the subject plant, division or subdivision ceased production or is stoppage scheduled?







Date of stoppage:

Is this permanent? 





If more than one product is produced, are workers separately identifiable by product?







Does the subject firm or parent company plan to import like or directly competitive products?







Has the subject firm or parent company, affiliates, branches, or subdivisions producing like or directly competitive products shifted production to another country or countries, or is a shift in production to another country scheduled?







If yes, to which country or countries? ____________________________________________ Date of the beginning of the shift:_______________________________________________ Date the shift completed:______________________________________________________

If separations at the subject firm occurred or are planned, explain the reasons for these separations.

G. If there were declines in subject firm sales or production within the time parameters listed in Question 7, briefly explain the reasons.

6. Secondary Impact:

Yes

No

Unknown

Does the subject firm conduct business with a firm whose workers have been certified under the TAA program?







If yes, please provide the name and address of the certified firm(s), and TA-W number(s), if known.

Name:

_______________________

Name:

_______________________

Name:

________________________

Address:

_______________________

Address

:_______________________

Address:

________________________

_______________________

_______________________

________________________

TA-W-

_______________________

TA-W-

_______________________

TA-W-

________________________

7. Subject Firm Employment, Sales, Production, and Imports:

If more than one article is produced at this location, reproduce and complete a form for each article. Otherwise, complete this page once.

Report the firm’s data for the articles identified below, including like or directly competitive articles, for the last two full years, the most recent year-to-date period, and the comparable period in the previous year. Please indicate whether your answers are in dollars or quantity*. If quantity is used, please provide the unit of measurement below. When reporting shifts in production to foreign countries, please use the space provided to specify which country production was shifted to and report for each foreign country on a separate line

Identify article(s) produced: ____________________________________________________________________________

200 

200 

JAN thru

  

JAN thru

  

200

 

200

 

Total Employment, including leased or temporary workers (Number)

Workers Age 50 or Over (Number)

Subject Location Sales

Dollars Quantity*

Company-wide Sales

Dollars Quantity*

Subject Location Production

Dollars Quantity*

Subject Location Exports

Dollars Quantity*

Production Shifted by the Subject Firm or Parent Company to Foreign Countries:

Dollars Quantity*

Country 1:

Country 2:

Country 3:

Total Company-wide Imports of Like or Directly Competitive Products

Dollars Quantity*

List countries where imports originated:

*Quantities provided are measured in:

(For example: units, dozens, pounds, tons)

Are numbers shown actual or estimates?

8a. Sales to Domestic Customers: For each article, include a list of the subject firm’s domestic customers that accounts for the majority of the decline in sales of the article identified. Reproduce and attach sheet(s) to provide information on the firm’s major declining customers. Report the firm’s data for the last two full years, the most recent year-to-date, and the comparable period in the previous year. Please indicate whether your answers are in dollars or quantity*. If quantity is used, please provide the unit of measurement. Identify articles (products): ____________________________________________________________________________

CUSTOMER(S)

200 

200 

Jan thru 200 

Jan thru 200 

Company Name:

.

Address:

Contact/Buyer:

Phone:

Fax:

E-mail:

Dollars  Quantity* 

Company Name:

Address:

Contact/Buyer:

Phone:

Fax:

Email:

Dollars  Quantity* 

Company Name:

Address:

Contact/Buyer:

Phone:

Fax:

Email:

Dollars  Quantity* 

Company Name:

Address:

Contact/Buyer:

Phone:

Fax:

Email:

Dollars  Quantity* 

Company Name:

Address:

Contact/Buyer:

Phone:

Fax:

Email:

Dollars  Quantity* 

*Quantities provided are measured in:

(For example: units, dozens, pounds, tons)

8b. Lost Bids: Relevant only if subject firm works on contractual basis. If applicable, list the major projects for which the subject firm submitted unsuccessful bids during the last two years. Reproduce and attach sheet(s) if needed to provide information for major contracts lost.

FIRM/AGENCY AWARDING BID

PROJECT DESCRIPTION

PROJECT INFORMATION

NAME:

PRODUCT:

ID#:

ADDRESS:

AMOUNT OF BID:

QUANTITY:

DATE OF AWARD:

CONTRACTING AGENT:

AWARDEE (IF KNOWN):

PHONE:

PERIOD OF PERFORMANCE:

FAX:

FIRM/AGENCY AWARDING BID

PROJECT DESCRIPTION

PROJECT INFORMATION

NAME:

PRODUCT:

ID#:

ADDRESS:

AMOUNT OF BID:

QUANTITY:

DATE OF AWARD:

CONTRACTING AGENT:

AWARDEE (IF KNOWN):

PHONE:

PERIOD OF PERFORMANCE:

FAX:

FIRM/AGENCY AWARDING BID

PROJECT DESCRIPTION

PROJECT INFORMATION

NAME:

PRODUCT:

ID#:

ADDRESS:

AMOUNT OF BID:

QUANTITY:

DATE OF AWARD:

CONTRACTING AGENT:

AWARDEE (IF KNOWN):

PHONE:

PERIOD OF PERFORMANCE:

FAX:

9. Alternative Trade Adjustment Assistance (ATAA): Given the current conditions of the job market in the local area are the skills of the worker group easily transferable to other positions in the commuting area? If “YES”, please explain. Yes  No  “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.”

TELEPHONE NUMBER

FAX NUMBER

E-MAIL

TITLE

COMPANY NAME

ADDRESS

COMPANY OFFICIAL NAME

SIGNATURE

DATE

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

ETA-9043a Rev. 09/08