ETA 8562A Customer Survey

U.S. Department of Labor Trade Adjustment Assistance Program TA-W-

OMB # 1205-0342 Exp. 11/30/09 Business Confidential Customer Survey Compliance Date:

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, city and state 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 unless directed otherwise. 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 a 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 at the U.S. Department of Labor:	     	E-Mail:     @dol.gov
	Phone: (202) 693- Fax: (202) 693-3986 or (202) 693-3585 or (202) 693-3584
Name of Customer and Location:

Part I

1. Report for the article or service your total purchases from the subject firm, other firms located in the United States, and firms located outside of the United States for the periods identified in the table below. Include like or directly competitive products or services. If there is no quantity or value, enter “zero” or “none”.

Article or Service:	     
	Purchases from the Subject Firm Purchases From Subject Firm Purchases/Contracts		Purchases from Other Firms Located in the U.S. Other Firms Located in the U.S. Purchases/Contracts			Imports into the U.S. Purchases from Firms Located Outside the U.S. 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 (for example: units, kilograms, pounds, tons or hours of work provided for under contract, value contract, number of phone calls, etc):
List countries where imports originated:

2. For purchases made from Other Firms Located in the U.S. (identified in Question 1), was the product wholly or partially manufactured or service performed in a foreign country? Yes  No 

a) If “Yes”, indicate percentage of [the service performed by workers] domestic purchases [manufactured] originating in foreign countries, if known:

2007:

______%

2008:

______%

Jan thru       2008:

______%

Jan thru       2009:

______%

List countries:

Are numbers shown actual or estimates?

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

4. Does your firm produce articles directly incorporating component parts supplied by the subject firm (identified in Question 1) or using services supplied by the subject firm (identified in Question 1) Yes  No 

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

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 reported increasing imports of the article or service identified in Question 1 OR answered “No” to Question 4, proceed to Part III, complete “Affirmative Information” and return this form to the DOL.

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.

5. Identify the article(s) into which your firm directly incorporates the components purchased from the subject firm or the article(s) produced using services supplied by the subject firm:

Article(s) Identified In Question 4
5. Report for the article(s) identified in Question 4 your total purchases from 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 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):
	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 value, 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. List all U.S. facilities of your firm, which produce articles incorporating components or services purchased from the subject firm:

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. Is your company switching from purchasing articles or services from the subject firm to purchasing articles or services from a supplier outside the U.S.? Yes  No 

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 article(s) identified in Question 4 incorporating U.S.-manufactured [subject firm component parts]:
20     	%	20     	%	Jan thru       20     	%	Jan thru       20     	%

8. For each article identified in Question 5, provide the information requested on this page for the periods requested below. Please provide the applicable unit of measurement below each table. If there is no quantity or dollar value, enter “zero” (0) or “none”.

Article identified in Question 5:			20     	20     		Jan thru       20     	Jan thru       20     
Your Firm’s Total Sales		Dollars
		Quantity*
Your Firm’s U.S. Imports which contain U.S. manufactured [ insert subject firm component part]		Dollars
		Quantity*
Your Firm’s U.S. Imports which contain non-U.S. manufactured [ insert subject firm component part]		Dollars
		Quantity*
List countries where U.S. imports originated:
*Quantities provided are measured in (for example: units, kilograms, pounds, tons):

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.

9. If you reported declining sales for the periods identified above, please provide a list of your firm’s foreign and domestic declining customers that account for the majority of your sales of the article identified in Question 5. Report the firm’s sales for the periods identified in the table below. Reproduce and attach additional sheets as necessary.

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:

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.

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

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

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 of Company Official:
TITLE:
Signature:						Date:
BUSINESS ADDRESS:
E-mail address:
telephone number:				FAX NUMBER:

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: 11/30/2009

Business Confidential Customer Survey Compliance Date:

U.S. Department of Labor Trade Adjustment Assistance Program

OMB No. 1205-0342 Expires: 11/30/2009

Red Means changes inserted.

Blue with strikeout means text deleted.

Green means combined with other text.

Page 6 of 6 For more information, visit our web site at http://www.doleta.gov/tradeact ETA-8562a

Rev. 4/09

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