Form ETA-9042a Petition

U.S. Department of Labor Employment and Training Administration OMB No. 1205-0342 Expires:

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 U.S. Department of Labor.

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, 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 U.S. Department of Labor in Washington, DC and the TAA coordinator or the dislocated worker office of the state where the firm/subdivision is located.

• To file with the U.S. 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 U.S. Department of Labor address provided below.

• 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 Form 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: 1-877-US2-JOBS (TTY) 1-877-889-5627
Internet: http://www.servicelocator.org

• Questions? Contact the U.S. Department of Labor at:

U.S. Department of Labor
Division of Trade Adjustment Assistance
Room N-5428 Phone 202-693-3560
200 Constitution Ave., N.W. Fax 202-693-3584, 3585
Washington, DC 20210 Internet http://www.doleta.gov/tradeact

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		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  (please check one) State Workforce Office  One-Stop Operator/Partner  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 Form 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.

a)	Name of Firm/Subdivision
b)	Street Address
	City
	State, Zip
c)	Phone
d)	Website (if appropriate)
e)	Federal Employer Identification Number (If known)
f)	What (if any) articles are produced at subject firm?
	If none are produced, what do workers do?
g)	How many workers have been or will be laid off?
h)	Is the plant closing?			If yes, when?

3. Provide contact information for two knowledgeable officials familiar with the trade effects at each firm/subdivision.

		Firm/Subdivision Official 1		Firm/Subdivision Official 2 (if known)
a) a)	Name
b)	Title
c)	Phone – Work
d)	Phone – Alternate
e)	Fax
f)	E-mail

4. Is the worker group (check the boxes that apply):

a) a)

Employed by a firm/subdivision that produces an article(s)

b) b)

Contracted to perform work for a firm/subdivision that produces an article(s)

Section 3. Trade Effects

5. In your opinion, has the firm or subdivision: (check appropriate box(es) below)

   a)				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)
   				Have the firm or subdivision’s customers increased imports
   b)				Supplied component parts for articles produced by a firm with a currently TAA-certified worker group
   c)				Assembled, finished or performed value-added production processes for articles provided by a firm with a currently TAA-certified worker group

6. If you checked Question 5(b) or 5(c) above, provide the following information for the firm with a currently TAA-certified worker group:

   a)	Firm Name
   b)	Street Address
   	City
   	State, Zip
   c)	Phone
   d)	Article(s) Produced
   e)	Certification Number and Date (If known)

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 Form 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)	Signature
b)	Name (Print)
c)	Date of Petition

The Petition Form 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 U.S. Department of Labor.

Petition Form Page 1 of 5 ETA-9042a

Rev. 9/08

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