ETA-9043c Business Confidential Data Request, firms that work on a

Business Confidential Data Request Firms Who Work on a Contractual Basis Compliance Date:

U.S. Department of Labor Trade Adjustment Assistance Program

OMB No. 1205-0342 Expires: XX/XX/XXXX

Processing Instructions

A petition for Trade Adjustment Assistance (TAA) has been filed on behalf of a group of workers. Your assistance in expeditiously completing this form 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 a certain time period following the filing date of the petition (19 U.S.C. 2273(a)). The Secretary of Labor is authorized to obtain this information through subpoena if you fail to comply with this request (19 U.S.C. 2272(e)(3)(B)). 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 firms with a decline in sales or a decline in production of articles or supply of services affected by imports of articles or services from foreign countries or shifts in production or services to foreign countries, and to workers in public agencies that have shifted the provision of a service to a foreign country. After receiving a TAA petition, TAA investigators analyze the facts to determine whether increased imports or shifts in production contributed importantly to the workers’ actual or threatened layoffs or work reductions and to determine whether the required minimum proportion of the workforce has either been laid off or is threatened with layoffs. The TAA Program provides petitioners with both rapid and early assistance. Once a petition has been granted and 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 additional reemployment assistance including long-term training while receiving income support and other benefits. These benefits are provided at no expense to employers.

Completing Form: 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, and attach any supporting documents. If you have any difficulty completing this form or have questions, please contact [Insert investigator name here].

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, in accordance with the Trade Act, 19 USC 2272 (e)(3)(c), the Trade Secrets Act, 18 USC 1905, the Freedom of Information Act, 5 U.S.C. 552, and 29 CFR Parts 70 and 90.

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 30 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 U.S. Department of Labor, Trade Adjustment Assistance Program, Room N-5428, 200 Constitution Ave., N.W., Washington, DC 20210 (Paperwork Reduction Project 1205-0342).

TA-W-
SUBJECT FIRM:
LOCATION:

A. LOST BIDS / CONTRACTS FOR ARTICLES

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/FAX:

PERIOD OF PERFORMANCE:

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/FAX:

PERIOD OF PERFORMANCE:

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/FAX:

PERIOD OF PERFORMANCE:

B. LOST BIDS / CONTRACTS FOR SERVICES

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 CONTRACT

CONTRACT DESCRIPTION

CONTRACT INFORMATION

NAME:

SERVICE:

VALUE OF CONTRACT:

ADDRESS:

DATE OF CONTRACT:

CONTRACTING AGENT:

AWARDEE (IF KNOWN):

PHONE:

PERIOD OF PERFORMANCE:

EMAIL:

FAX:

FIRM/AGENCY AWARDING CONTRACT

CONTRACT DESCRIPTION

CONTRACT INFORMATION

NAME:

SERVICE:

VALUE OF CONTRACT:

ADDRESS:

DATE OF CONTRACT:

CONTRACTING AGENT:

AWARDEE (IF KNOWN):

PHONE:

PERIOD OF PERFORMANCE:

EMAIL:

FAX:

FIRM/AGENCY AWARDING BID

CONTRACT DESCRIPTION

CONTRACT INFORMATION

NAME:

SERVICE:

VALUE OF CONTRACT:

ADDRESS:

QUANTITY:

DATE OF CONTRACT:

CONTRACTING AGENT:

AWARDEE (IF KNOWN):

PHONE:

PERIOD OF PERFORMANCE:

EMAIL:

FAX:

Affirmation of Information
The information you provide on this form will be used for the purposes of determining worker group eligibility. Knowingly falsifying any information on this form is a Federal offense (18 USC § 1001) and a violation of the Trade Act (19 USC § 2316). 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 on this form is true, correct, and complete.”
Name and Title of Company Official:
Signature of Company Official:							Date:
E-mail address:
telephone number:				FAX NUMBER:

Please provide contact information for individuals who may be contacted with follow-up questions, if different from the company official signing the affirmation.

		Part 1		Part 2
a) a)	Name
b)	Title
c)	Phone – Work
d)	Phone – Alternate
e)	Fax
f)	E-mail

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

ETA-9043c Rev. 4/09