ETA 9043B CDR Service Changes

Business Confidential Data Request Firms that Supply a Service Compliance Date:

U.S. Department of Labor Trade Adjustment Assistance Program

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

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 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 4 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).

TA-W - :	[     ]
Subject Firm:	[     ]
Location:	[     ]
Contact at the U.S. Department of Labor [ ]	Phone: (202) 693- Fax: (202) 693-3986; (202) 693-3585; (202) 693-3584	E-Mail:     @dol.gov
ATTENTION Public Agency respondent. For the purpose of this collection of information, the term “subject firm” or any similar reference to the “firm” is intended to include a public agency. Instructions: 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].

Part I
A. Subject Firm/Public Agency Information
(1) Official Subject Firm Name							Division (if any)
	Address
	Website
(2) Parent company of Subject Firm (if applicable)
	Address
(3) Federal Employer Identification No. (FEIN): ____________________
	(a) In the past one year, have the workers’ wages been reported under another FEIN? Yes  No 
	(b) If yes, explain why and list the other FEIN and the corporate name for the other FEIN:
(4) Provide the names and addresses of all companies supplying leased or temporary workers to the subject firm to supplement the firm’s workforce in the past year and describe their functions.
B. Organizational Structure
(1) Describe the organizational structure of the subject firm, including, but not limited to, the parent company, affiliates and subsidiaries. and any other subdivisions supplying services that are like or directly competitive with the services supplied at the subject firm? Are there any other subdivisions manufacturing articles that are like or directly competitive with the articles manufactured at the subject firm? (Please attach any existing diagrams of organizational structure.)
			(2) In the space below, provide the name and address of all contractors and staffing agencies supplying leased or temporary workers to the subject firm in the past one year and describe their functions.

C. Services Supplied
(1) Describe the services supplied by the subject firm. If the firm does not supply a service, stop here and contact the Department of Labor investigator assigned to your case.
(2) Identify the North American Industry Classification System (NAICS) code(s) for the subject firm.
(3) If more than one service is provided at the subject firm, are workers (including leased workers) separately identifiable by service? Yes  No 
If yes, please explain.

Part II

A. Recent Employment Activities of Subject Firm

(1) Have worker separations occurred or are any expected? (Include leased or temporary workers) Yes  No 

1. How many workers were separated at the subject firm since (insert beginning impact date)?_______________

2. If future worker separations are planned or expected in the future, when will they occur?

3. How many total workers do you expect to will be separated?

4. Have workers’ wages and hours been reduced?

Yes  No 

Yes  No 

(2) Explain the reasons for these separations and/or the reductions in wages or hours. If you believe the separations are/were caused in any way by the effects of foreign trade, please describe.

(3) Has the subject firm ceased operating or is a shutdown scheduled? Yes  No 

(a) If yes, date of shutdown: ­­­­­­­­­­­­­­­­________________

(b) Is this the shutdown permanent? Yes  No 

(4) Has the subject firm or parent company, affiliates, branches, or subdivisions imported or acquired from a foreign country services like or directly competitive with the services supplied by the subject firm? Yes  No 
(5) Has the subject firm or parent company, affiliates, branches, or subdivisions supplying like or directly competitive services shifted that work to another country or countries, or is a shift of services to another country scheduled? Yes  No 
a) If yes, date of the beginning of the shift:			b) Date the shift completed:
(6) Has the subject firm contracted to have this service supplied outside the United States? Yes  No 
(a) If yes, explain the arrangement and describe the services that will be provided:
(7) Are the services supplied by the subject firm supplied to another division or a parent company or affiliate that is producing an article? (For example, the workers at the subject firm perform accounting services for a location that manufactures engines) Yes  No 
(a) If yes, include the division, parent company, or affiliate in the customer list requested in section C.

(8) Are the worker separations caused in any part by the subject firm, parent company, or affiliates importing any articles like or directly competitive with articles produced using the services supplied by the workers at the subject firm? Yes  No 
(a) If yes, please explain:

IMPORTANT!

If your company increased imports of services or shifted the supply of services identified above in part I.C.1 to a foreign country, stop here and contact the Department of Labor investigator assigned to your case for further instructions.

A. Recent Shifts in Services and Imports
(1) Has the subject firm or parent company, affiliates, branches, or subdivisions imported or acquired from a foreign country services like or directly competitive with the services supplied by the subject firm? Yes  No 
(2) Has the subject firm or parent company, affiliates, branches, or subdivisions supplying like or directly competitive services shifted that work to another country or countries, or is a shift of services to another country scheduled? Yes  No 
(a) If yes, on what date did or will the shift begin?
(b) On what date was the shift completed?
(3) Has the subject firm contracted to have this service supplied outside the United States? Yes  No 
(a) If yes, explain the arrangement and describe the services that will be provided:
(4) Are the services supplied by the subject firm supplied to another division or a parent company or affiliate that is producing an article? (For example, the workers at the subject firm perform accounting services for a location that manufactures engines) Yes  No 
(a) If yes, include the division, parent company, or affiliate in the customer list requested in section C.

(5) Are the worker separations caused in any part by the subject firm, parent company, or affiliates importing any articles like or directly competitive with articles produced using the services supplied by the workers at the subject firm?

Yes  No 

(6) Has your firm lost bids for contracts to supply services in the past 2 years? Yes  No 

B. Subject Firm Employment, Sales, Production, and Imports

Report the firm’s data for the service identified for the last two full years, the most recent year-to-date period, and the comparable period in the previous year. Please provide the applicable unit of measurement below each table. If more than one service is provided at this location, reproduce and complete a form for each service.

Identify Service:

		20  		20  		Jan thru     20  		Jan thru     20  
Employment (including leased or temporary workers) associated with this service
Total Sales (This location only)	Dollars
	Quantity*
Exports (Services supplied to foreign countries from this location only)**	Dollars
	Quantity*
U.S. Imports Firm-wide (Including Like or Directly Competitive Services)	Dollars
	Quantity*
U.S. Imports Firm-wide of Articles Produced Using Services Like or Directly Competitive with the Services Identified Above	Dollars
	Quantity*
List countries where imports originated:
Services Shifted by the Subject Firm or Parent Company From this Location to Foreign Countries:	Dollars
	Quantity*
List countries involved in the shifts in services:

* Quantities provided are measured in:			(For example: labor hours, value of contract)
** Export data is required for the Department’s analysis in its investigation.
Are numbers shown actual or estimates?

B. Subject Firm Sales, Production, and Imports

Provide the information requested on this page for each service supplied by the subject firm. Reproduce and attach additional sheets as necessary. Report the firm’s data for the service identified for the last two full years, the most recent year-to-date period, and the comparable period in the previous year. Please provide the applicable unit of measurement below each table.

Identify Service:

		20  	20  	Jan thru     20  	Jan thru     20  
Sales (This location only)	Dollars
	Quantity*
Exports (Services supplied to foreign countries from this location only)**	Dollars
	Quantity*
Imports Firm-wide (Including Like or Directly Competitive Services)	Dollars
	Quantity*
Imports Firm-wide of Articles Produced Using Services Supplied by the Workers	Dollars
	Quantity*
List countries where imports originated:
Services Shifted From this Location to Foreign Countries:	Dollars
	Quantity*
List countries involved in the shifts in services:

* Quantities provided are measured in:			(For example: labor hours, value of contract)
** Export data is required for the Department’s analysis in its investigation.
Are numbers shown actual or estimates?

E. Total Employment / Employment per Service at Subject Firm
	20     	20     	Jan thru       20     	Jan thru       20     
Total employment, including leased or temporary workers, salaried and hourly (Number)
Are any leased or temporary workers included in these numbers? Yes  No 

If the firm supplies more than one service, but workers are dedicated to work related to one specific service at the subject firm indicate the number of workers for each service in the table provided below (for example, the number of workers who perform accounting services). Report the firm’s data for the service identified for the last two full years, the most recent year-to-date period, and the comparable period in the previous year. Reproduce and attach additional sheets as necessary.
	20     	20     	Jan thru       20     	Jan thru       20     
Service: ___________________________ Number
Service: ___________________________ Number
Service: ___________________________ Number
Service: ___________________________ Number

C. Secondary Impact

(1) Does the subject supply services to a firm whose workers have been certified under the TAA program? Yes  No 

(a)If yes, please describe the business relationship with the TAA-certified firm and include the TAA certified firm in the list of customers provided in section D.

D. Sales to Customers
For each service supplied by the subject firm, provide a list of the subject firm’s customers that account for the majority of the decline in sales of the service identified. Report the subject firm’s data for the last two full years, the most recent year-to-date, and the comparable period in the previous year. Also identify any articles produced using the service identified (for example, HR services supplied to a customer that manufactures engines). Reproduce and attach additional sheet(s) as necessary.
Identify service:

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

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

* Quantities provided are measured in:		(For example: labor hours, value of contract)
Are numbers shown actual or estimates?

If the service is used to produce an article, identify the article:

E. LOST BIDS / CONTRACTS FOR SERVICES

Has your firm lost bids for contracts to supply the services by the subject firm in the past 2 years? Yes  No 

If yes, 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:

Service:

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:

Service:

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:

Service:

ID#:

Address:

Amount of Bid:

Quantity:

Date of Award:

Contracting Agent:

Awardee (If Known):

Phone/Fax:

Period Of Performance:

AWARDEE (IF KNOWN):

Part III

Affirmation of Information
The information you provide on this form will be used for the purposes of determining worker group eligibility and to estimate the total number of workers covered by the petition. 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:

Provide contact information for individuals who may be contacted with follow-up questions relating to questions in Part I and Part II of this form, if different from the company official signing the affirmation.

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

Red means changes inserted.

Blue with Strikeout means text deleted.

Green means combined with other text.

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

ETA-9043b Rev. 4/09