ED-840P Print vers Petition by a Firm for Certification of Eligibilityto Ap

Form ED-840P
OMB Control No. 0610-0091
Expires:

iii

Economic Development Administration
PETITION BY A FIRM FOR CERTIFICATION OF ELIGIBILITY
TO APPLY FOR TRADE ADJUSTMENT ASSISTANCE
The Trade Adjustment Assistance for Firms Program (the “TAA Program”) is authorized by
chapters 3 and 5 of title II the Trade Act of 1974, as amended (19 U.S.C. § 2341 et seq.) (the
“Trade Act”). The TAA Program provides technical assistance to help U.S. firms experiencing a
decline in sales and employment, resulting in important part from the increase in imports of like or
directly competitive articles, to become more competitive in the global marketplace. The Secretary
of Commerce is responsible for administering the TAA Program and has delegated the statutory
authority and responsibility under the Trade Act to the U.S. Department of Commerce’s Economic
Development Administration (“EDA”). EDA regulations implementing the TAA Program are
codified at 13 C.F.R. part 315 and may be accessed via EDA’s Internet website at:
http://www.eda.gov.
For additional information on the TAA Program or to find the Trade Adjustment Assistance
Center (“TAAC”) serving your geographic region, please visit the Trade Adjustment
Assistance for Firms Internet website at: http://www.taacenters.org.

Petition By A Firm For Certification of Eligibility
To Apply For Trade Adjustment Assistance (Form ED-840P)
OMB Control No. 0610-0091
Expires:
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for
failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, as amended,
unless the collection of information displays a currently valid OMB Control Number.
The information requested in the Petition by a Firm For Certification of Eligibility to Apply for Trade Adjustment Assistance (Form
ED-840P) is required to obtain or retain benefits from the Economic Development Administration (EDA) pursuant to chapters 3 and 5
of title II the Trade Act of 1974, as amended (19 U.S.C. 2341 et seq.). EDA uses information collected on Form ED-840P and in
accompanying documents to determine if a firm is eligible to apply for Trade Adjustment Assistance. The information submitted on
Form ED-840P and in accompanying documents is subject to public disclosure under the Freedom of Information Act, unless
exempt from disclosure as trade secrets or privileged or confidential commercial or financial information under 5 U.S.C. §
552(b)(4).
The public reporting burden for this collection of information is estimated to average 8 hours per response, including time for
reviewing instructions, gathering data and completing the Form ED-840P. Comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing paperwork burden may be sent to: U.S. Department of
Commerce, Economic Development Administration, TAA Program Manager, 1401 Constitution Avenue N.W., Room 7009,
Washington, D.C. 20230, and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington,
D.C. 20503.

DEPARTMENT OF COMMERCE
ECONOMIC DEVELOPMENT ADMINISTRATION

Form ED-840P U.S.
OMB Control No. 0610-0091
Expires:

PETITION BY A FIRM FOR CERTIFICATION OF ELIGIBILITY
TO APPLY FOR TRADE ADJUSTMENT ASSISTANCE
No firm may be certified unless this petition is completed. (See 19 U.S.C. § 2341; 13 C.F.R. part 315)
FOR GOVERNMENT USE ONLY
E-MAIL TO:
[email protected]
Project Number
Date Accepted
OR
for Filing
SUBMIT TO: U.S. Department of Commerce Economic Development
Administration Trade Adjustment Assistance Program Manager
1401 Constitution Avenue, N.W., Room 7009
Washington, D.C. 20230

ITEM 1 - PETITIONING FIRM
Name and address of petitioning firm (Use the legal name of the firm and indicate any trade name)
Company Name:
Address:
City:
State:
Zip Code:
Contact Person
First Name:
Last Name:
Title:
Salutation:
ITEM 2 - LEGAL FORM OF PETITIONING FIRM
Legal Form of petitioning firm (Please check appropriate box)
Single Proprietorship

Partnership

Corporation

Telephone Number
(Include Area Code):

E-mail Address:

Other (please specify)________________

ITEM 3 - RELATED FIRMS
Check if one or more of the following apply and attach a detailed explanation (See General Instructions to Item 3):
Petitioning firm is a "successor firm".
Petitioning firm is a subsidiary, affiliate, predecessor, or otherwise related by common ownership or common control to
another firm. Indicate in the attached explanation whether the petitioning firm and the related firm sell or produce like or
directly competitive articles.
ITEM 4 - HISTORY OF PETITIONING FIRM
Attach a brief narrative describing the petitioning firm's economic history (See General Instructions to Item 4).
ITEM 5 - ARTICLES PRODUCED AND SOLD (Attach a separate sheet if necessary)
A.
Describe in detail the articles produced by the petitioning firm that are adversely affected by import competition,
including a brief description of the manufacturing process and the principal materials incorporated into the finished
articles.

B.

If applicable, describe in detail any other articles produced by the petitioning firm that are not adversely affected by
import competition.

C.

If applicable, describe in detail any finished articles purchased for resale by the petitioning firm and indicate whether such
articles are imported and from what country.

ITEM 6 - SALES/PRODUCTION DATA (See General Instructions to Item 6)
Petition Time Period
(This period should be the same for import data and employment data)

_____________
(Ending Date)

_____________
(Ending Date)

Percent Change

A. Total net sales or production of all articles produced by the
petitioning firm.
B. Total net sales of all articles purchased for resale by the
petitioning firm

C. Total net sales or production of all import-impacted articles
produced by the petitioning firm.
D. Specify if one or more of the following apply to the sales of the import-impacted articles (See 13 C.F.R. § 315.2 and 315.7(b)(1)):

Absolute decline in sales of the import-impacted articles.
Interim decline in sales of the import-impacted articles. If checked, please specify the number of months:
"25 percent" rule applies.
"Self-inflicted wound" (i.e., petitioning firm is purchasing the import-impacted articles offshore).
Sales decline is determined based on a bid or a quote.
ITEM 7 - IMPORT DATA (See General Instructions to Item 7 and attach additional sheets as necessary)
DUNS Number:

Petition Time Period

NAICS (5-digit):

Harmonized Tariff Schedule (HTS) No.:

HTS No. Description:

_____________
(Ending Date)

_____________
(Ending Date)

Percent Change

Total Value of Imports in U.S. Dollars ($000s):
ITEM 8 - EMPLOYMENT DATA (See General Instructions to Item 8)
Petition Time Period
_____________
(Ending Date)
A.

Petitioning firm's total monthly average
employment.

B.

Petitioning firm's total monthly average
employment of production and related workers for
all import-impacted articles.

_____________
(Ending Date)

C. Specify if one or more of the following apply to the firm's total employment:
There is an interim decline in employment (See 13 C.F.R. § 315.8).
There is a partial employee separation (A decline in worker hours or wages. See 13 C.F.R. § 315.2).
The threat of total or partial employee separation is imminent. Please attach supporting documentation. (See 13
C.F.R. § 315.2).
An employee of the petitioning firm has petitioned the U.S. Department of Labor for certification
of eligibility to apply for Trade Adjustment Assistance for Workers. If so, please provide the following:
U.S. Department of Labor case number:
Describe the disposition (or current status) of the case:

Percent Change

ITEM 9 - FINANCIAL REPORTS
Attach one (1) copy of the complete auditor's certified financial reports for the petitioning firm (including any subsidiaries,
affiliates and other related entities) for the entire period covered by the petition. If certified financial statements are not available,
furnish one (1) copy of the complete profit and loss statements, balance sheets and supporting statements prepared by the
petitioning firm's accountants for the entire period covered by the petition. Publicly-owned corporations should furnish one (1)
copy of each Form 10-K annual report (or Form 10-Q quarterly report, as appropriate) filed with the U.S. Securities and Exchange
Commission for the entire period covered by the petition.
ITEM 10 - CUSTOMER LIST
During the investigation of a firm's petition, a representative group of the firm's customers will be contacted to determine whether
there is a relationship between any import-impacted sales and employment declines experienced by the firm and any increases in
the value of like or directly competitive articles being imported into the United States. To facilitate this investigation, attach a
separate sheet providing:
(i)
the names and addresses of four (4) important current or important recent customers of the petitioning firm
(especially those that have reduced their purchases from the petitioning firm);
(ii)
the names and business telephone numbers of contact persons for each customer; and
(iii)
data on sales volume to each of the listed customers for the entire period covered by the petition.
If the petitioning firm does not have repeat customers, include a list of potential customers to whom the firm has submitted bids,
but lost contracts to foreign suppliers (copies of the lost bids should also be included). Include only customers who were active or
potential customers of the petitioning firm during the period covered by the petition.
ITEM 11 - PETITION ASSISTANCE
If a Trade Adjustment Assistance Center ("TAAC") helped prepare this petition, please identify the TAAC and the name and
telephone number of your contact person at the TAAC. Additionally, please identify the name, business address and telephone
number of anyone outside of the petitioning firm and the TAAC who assisted in preparing this petition.
TAAC Name:
Address:
City, State, Zip-Code:
Contact Name:

Contact E-mail:

ITEM 12 - CERTIFICATION
The undersigned is an authorized representative of the petitioning firm and is executing this certification on behalf of the
petitioning firm. The undersigned hereby certifies that the information contained in or submitted with this petition is correct and
complete to the best of his/her knowledge and belief. U.S. Code, title 18 (Crimes and Criminal Procedure), Section 1001, makes it
a criminal offense to knowingly and willfully make any false statement or representation to any department or agency of the
United States as to any matter within its jurisdiction.
Name of Authorized Representative

Signature of Authorized Representative

Title

Date

GENERAL INSTRUCTIONS
NUMBER OF COPIES: Submit one (1) original, signed copy of the petition and any attachments to the address
provided at the top of the Petition by a Firm for Certification of Eligibility to Apply for Trade Adjustment Assistance
(Form ED-840P). EDA’s acceptance of a petition will be delayed if the Form ED-840P and the appropriate supporting
documentation are not completed in accordance with these instructions.
ELIGIBILITY: A petitioning firm must complete and file a Form ED-840P in order for EDA to determine its eligibility
to apply for Trade Adjustment Assistance. For purposes of determining eligibility, a firm, together with any predecessor
or successor firms, subsidiary firms, or any affiliated firms beneficially owned or controlled by substantially the same
person or persons, may be considered a single firm (petitioner) when they produce like or directly competitive articles or
are exerting essential economic control over one or more production facilities. See the definition of “Significant Number
or Proportion of Workers" in 13 C.F.R. § 315.2.
To establish eligibility, a firm must demonstrate the following: (i) a significant number or proportion of the workers in
the firm have been (or are threatened with becoming) totally or partially separated; (ii) sales or production, or both, of the
firm have decreased absolutely (or sales and production of an article accounting for at least 25 percent of the firm’s sales
or production during the two most recent consecutive twelve-month periods for which data are available have decreased
absolutely; this is otherwise known as the "25 percent" rule); and (iii) increases of imports of articles like or directly
competitive with those produced by the firm have contributed importantly to the separation (or threat of separation) and
to the decline in sales or production. In some cases, an interim decline in sales or employment may satisfy the eligibility
requirements. See 13 C.F.R. § 315.7 for a detailed explanation of the certification requirements.
ITEM 3 – RELATED FIRMS: Provide the name and address of any subsidiary, affiliate, predecessor or successor
firm, co-venturer, and any other related firm. In addition, describe (if applicable) the ownership of each of the related
firms (including the names of the owners and their respective ownership percentages), the relationship of the firms to
each other, the type of business each firm is engaged in, the nature and amount of any intercompany transactions, and
indicate whether each related firm is currently conducting business. Information about a related firm should be included
as part of the petition whether or not (i) such firm’s operations are related to the activities of the petitioner, (ii) its
activities have been affected by import competition, or (iii) it is engaged in manufacturing activities.
ITEM 4 – HISTORY OF PETITIONING FIRM: Please attach a narrative discussing (at a minimum) the following
items as each pertains to the petitioning firm:
(a)
(b)
(c)
(d)
(e)
(f)
(h)
(i)
(j)

Year founded;
Type of business;
A detailed description of all goods produced, articles sold and services provided;
Number, location, and nature of business of all manufacturing, production, distribution and sales facilities, both
domestic and foreign;
Markets served by the petitioning firm;
Names and titles of officers, directors, and senior management of the petitioning firm;
Significant ownership or management changes in the past 5 years;
Important events in the recent history of the petitioning firm, such as but not limited to natural disasters, fires,
labor strikes, changes in product mix; and
Any other information germane to the petition.

ITEM 6 – SALES/PRODUCTION DATA: Provide sales and /or production data for the period covered by the petition.
The period covered by the petition must not end more than 120 days prior to the date the petition is submitted to EDA for
investigation. If a firm has export or other foreign sales or productions operations, attach a separate sheet describing the
foreign output and employment data separately from domestic output and employment data. List only net sales “F.O.B.
Point of Shipment” and exclude interplant transfers, returned goods, discounts, and other intercompany transactions or
allowances.
ITEM 7 – IMPORT DATA: Provide the U.S. Harmonized Tariff Schedule (“HTS”) number and basket description for
each like or directly competitive import-impacted article identified in Item 6. Also provide the total value (in thousands
of U.S. dollars) of the imported articles attributable to each HTS number.

(General Instructions continued)
ITEM 8 – EMPLOYMENT DATA: Calculate the total average monthly employment for all of the petitioning firm’s
employees for the entire period covered by the petition. Separately calculate the total average monthly employment for
all production and related workers for all import-impacted articles reported in Item 6. Monthly employment generally
includes both full- and part-time employees. See 13 C.F.R. §§ 315.2 and 315.7. If any group of employees of the
petitioning firm has petitioned the U.S. Department of Labor for certification of eligibility to apply for trade adjustment
assistance for workers, you may authorize the release to the U.S. Department of Commerce of any information obtained
by the U.S. Department of Labor during its investigation of the worker’s case by calling the U.S. Department of Labor,
Division of Trade Adjustment Assistance, at (202) 693-3560 or by a letter of authorization. The letter should be
addressed and mailed to the Director, Division of Trade Adjustment Assistance, Room C-5311, Employment and
Training Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. Please
include a copy of your letter with this petition. Access to the U.S. Department of Labor records may expedite the
processing of this petition.