ETA-8562 Business Confidential Customrer survey, first tier purch

Business Confidential Customer Survey First Tier Purchasers of Articles 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 at [insert subject firm's name here]. As a customer of that firm, the U.S. Department of Labor needs your help in determining whether that firm has been hurt by foreign trade. 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 2.5 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, Trade Adjustment Assistance Program, Room N-5428, 200 Constitution Ave., N.W., Washington, DC 20210 (Paperwork Reduction Project 1205-0342).

Reference Number: TA-W-

     

Subject Firm:

     

Location:

     

Contact Person at the U.S. Department of Labor:

     

Phone: (202) 693-

     

Fax:

(202) 693-3585

E-Mail:

     

@dol.gov

Name of Customer and Location: ____________________________________________________________________________

1. Report for the article below your total purchases from the s, other firms located in the United States, and firms located outside of the United States for the last two full years, the most recent year-to-date, and the comparable period in the previous year. Include like or directly competitive products. If there is no quantity or value, enter “zero” or “none”.

[Article]
	Purchases from      			Purchases from Other Firms Located in the U.S.				Purchases from Firms Located Outside the U.S.
Period	Quantity*		Dollars	Quantity*		Dollars		Quantity*		Dollars
20      (Full Year)
20      (Full Year)
Jan thru      20     
Jan thru      20     
*Quantities provided are measured in (for example: units, kilograms, pounds, tons):

2. For purchases made from Other Firms Located in the U.S. (identified in Question 1), was the product manufactured in a foreign country? Yes  No 
a) If “Yes”, indicate percentage of domestic purchases manufactured in foreign countries, if known:
20     	%	20     	%	Jan       thru 20     	%	Jan thru       20     	%

3. If your company’s purchases from      have declined, please explain why:

4. Identify any article(s) into which you directly incorporate the [articles] purchased from     :

Article(s) Identified In Question 4
5. Report for the article(s) identified in Question 4 your total purchase from firms located in the U.S. firms and firms located outside the U.S. for the last two full years, the most recent year-to-date, and the comparable period in the previous year in the table below. Include like or directly competitive products. If there is no quantity or dollar, enter “zero” (0) or “none”.
	Purchases from Firms Located in the U.S			Purchases from Firms Located Outside the U.S.
Period	Quantity*		Dollars	Quantity*			Dollars
20      (Full Year)
20      (Full Year)
Jan thru      20     
Jan thru       20     
*Quantities provided are measured in (for example: units, kilograms, pounds, tons):

6. For purchases made from firms located in the U.S. (identified in Question 5), was the product manufactured in a foreign country? Yes  No 
a) If “Yes”, indicate percentage of U.S. purchases manufactured in foreign countries, if known:
20     	%	20     	%	Jan       thru 20     	%	Jan thru      20     	%

7. For purchases made from firms located outside the U.S. (identified in Question 5), did the articles incorporate [subject firm component parts] manufactured in the U.S.? Yes  No 
a) If “Yes”, indicate percentage of Non-U.S.-manufactured [finished articles] incorporating U.S.-manufactured [subject firm component parts]:
20     	%	20     	%	Jan       thru 20     	%	Jan thru       20     	%

8. Has your firm experienced a decrease in sales of articles identified in Question 4 to your customers during the time periods listed above? Yes  No 
9. If known, identify any countries that are the sources of any imports identified in the questions above:

IMPORTANT!!!

If you answered “No” to Question 8, return this form to the Department of Labor. If you answered “Yes” to Question 8, please proceed to and complete Question 10.

10. For each finished article identified in Question 4 above, provide a list of your firm’s foreign and domestic customers that account for the majority of your sales of the article identified. Report the firm’s sales for the last two full years, the most recent year-to-date, and the comparable period in the previous year. Reproduce and attach additional sheet(s) as necessary.
Identify article:

20     

20     

Jan thru       20     

Jan thru       20     

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Phone:

Fax:

Email:

20     

20     

Jan thru       20     

Jan thru       20     

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Phone:

Fax:

Email:

20     

20     

Jan thru       20     

Jan thru       20     

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Phone:

Fax:

Email:

							20     	20     	Jan thru       20     	Jan thru       20     
Company Name:						Dollars
Address:
Contact/Buyer:						Quantity*
Phone:				Fax:
Email:

*Quantities provided are measured in:		(For example: units, kilograms, pounds, tons.)
Are numbers shown actual or estimates?

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 is true, correct, and complete.”
Name and Title of Company Official:
Signature of Company Official:						Date:
E-mail address:
telephone number:				FAX NUMBER:

Page 5 of 5 For more information, visit our Web site at http://www.doleta.gov/tradeact ETA-8562a

Rev. 4/09

Previous forms not usable