ETA-8562b Business Confidential Customer Survey Services

Business Confidential Customer Survey Services 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 2 hours, 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 service below your total purchases from     , other firms located in the U.S., 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. Include like or directly competitive services. If there is no quantity or value, enter “zero” or “none”.

[Service]
	Subject Firm Purchases/Contracts			Other Firms Located in the U.S. Purchases/Contracts				Firms Located Outside the U.S. Purchases/Contracts
Period	Quantity*		Dollars	Quantity*		Dollars		Quantity*		Dollars
20      (Full Year)
20      (Full Year)
Jan thru       20     
Jan thru       20     
*Quantities provided are measured in (ex: hours of work provided for under contract, value of contract, number of phone calls or other services performed) :

For purchases made from Other Firms Located in the U.S. (identified in Question 1), was the service performed in a foreign country? Yes  No 
If “Yes”, indicate percentage of the service performed by workers in a foreign country, for each relevant time period:
20     	%	20     	%		Jan       thru 20     	%	Jan       thru 20     	%
List countries:
Are numbers shown actual or estimates?

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

4. Are the services supplied by the subject firm directly used to produce an article? Yes  No 
If yes:
(a) Identify any articles produced using services supplied by the subject firm:
(b) Is the decline in purchases from the subject firm caused by your company importing articles like or directly competitive with the articles produced using the services supplied by the subject firm? Yes  No 
(c) To the best of your knowledge, is the decline in purchases from the subject firm caused by your company’s customers importing articles like or directly competitive with the articles produced using the services supplied by the subject firm? Yes  No 

IMPORTANT!!

If you answered “No” to Question 4 return this form to the Department of Labor.

If you answered “Yes” to Question 4 (a) , please proceed to and complete Question 5.

If you answered “Yes” to Question 4 (b), please proceed to and complete Question 6.

Article(s) Identified in Question 4

5. Report the firm’s data for imports of the article produced using the services supplied by the subject firm (or those like or directly competitive with it) 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”.

Articles Identified in Question 4			20     	20     		Jan thru       20     	Jan thru       20     
Imports including like or directly competitive articles		Dollars
		Quantity*
*Quantities provided are measured in (for example: units, kilograms, pounds, tons):
Numbers shown are actual or estimates?

6. Provide a list of your firm’s customers that account for the majority of the decline in the sales of the article(s) produced using the services supplied by the subject firm.

CUSTOMER(S):

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

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

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

			20     	20     	Jan thru       20     	Jan thru       20     
Company Name:		Dollars
Address:
Contact/Buyer:		Quantity*
Phone:
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 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-8562b

Rev. 4/09