ETA-9043a Business Data Request

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

OMB # 1205-0342 Exp. 1/31/2013 Business Confidental Data Request (Article) Compliance Date:

Processing Instructions

A petition for Trade Adjustment Assistance (TAA) and Alternative Trade Adjustment Assistance (ATAA) 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. 2321). 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. After receiving a TAA and ATAA petition, TAA investigators analyze the facts to determine whether increased imports or shifts in production or services 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 to determine whether the criteria for certification of the workers covered by 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 (d)(3)(c), Trade Secrets Act, 18 USC 1905 and the Freedom of Information Act, 5 U.S.C. 552(b)(4), and 29 CFR Parts 70 and 90, and Executive Order 12600, dated June 23, 1987 (352 FR 23781, June 25, 1987).

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, Office of Trade Adjustment Assistance, 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:	     	E-Mail:     @dol.gov
	Phone: (202) 693-       Fax: (202) 693-3986; (202) 693-3585; (202) 693-3584

Part I

A. Subject Firm Information

(1) Official Subject Firm Name

Division (if any)

Address

Website

(2) 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:

(3) Parent company of Subject Firm (if applicable)

Address

(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
Describe the organizational structure of the subject firm, including, but not limited to, the parent company, affiliates and subsidiaries. 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.)

C. Articles Produced
(1) Describe the articles manufactured by the subject firm and their end uses. If the firm does not produce an article, 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, and the Harmonized Tariff Schedule (HTS) classification for the articles produced there, if known:
(3) Are the articles produced by the subject firm incorporated as components into another article? Yes  No 
If yes, please identify the finished article(s) into which these components are incorporated.
(4) If more than one product is produced at the subject firm, are workers (including leased workers) separately identifiable by product? Yes  No 
If yes, please explain.

Part II
A. Recent Activities of Subject Firm
Have worker separations occurred or are any expected? (Include leased or temporary workers) Yes  No 
How many workers were separated at the subject firm since (insert beginning impact date)?_______________ If future worker separations are planned or expected, when will they occur? _________________ How many workers will be separated? ________________ Have workers’ wages and hours been reduced? Yes  No 
(2) Explain the reasons for these separations and the reduction in wages and hours. If you believe the separations are/were in any way caused by the effects of foreign trade, please describe.
(3) Do the workers in the workers’ firm possess skills that are not easily transferable? Yes  No 
(4) Has the subject firm ceased operating or is a shutdown scheduled? Yes  No 
(a) If yes, date of shutdown: ________________ (b) Is the shutdown permanent? Yes  No 
(5) Has the subject firm or parent company, affiliates, branches, or subdivisions imported or acquired from a foreign country articles that are like or directly competitive with articles produced by the subject firm? Yes  No 
(6) Has the subject firm or parent company, affiliates, branches, or subdivisions imported any finished products that incorporate an article like or directly competitive with the article produced by the workers at the subject firm? (For example, the subject firm produces manifolds and the parent company imports engines) Yes  No 
(7) Has the subject firm or parent company, affiliates, branches, or subdivisions producing like or directly competitive articles shifted that work to another country or countries, or is a shift in production to another country scheduled? Yes  No 
a) If yes, date of the beginning of the shift:				b) Date the shift completed:
(8) Has the subject firm contracted to have the article produced outside the United States? Yes  No 
If yes, explain the arrangement and describe the article that will be produced:

(9) To the best of your knowledge, is your firm experiencing a decline in sales caused by customers purchasing non-U.S. manufactured articles rather than the articles produced by your firm? Yes  No  If yes, please explain.
(10) Is your firm experiencing a decline in sales to a customer located outside the United States? Yes  No 
(a) If yes, does the customer located outside the United States incorporate the articles produced by your firm into a product that is then imported into the United States? Yes  No 
IMPORTANT! If your company increased imports of articles or shifted production of articles 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.
B. Subject Firm Employment, Sales, Production, and Imports
Report the firm’s data for the articles identified below, including like or directly competitive articles, for the periods provided in the table. Please provide the applicable unit of measurement below each table. If more than one product is produced at this location, reproduce and complete a form for each product.

Article Produced:

20     

20     

Jan thru       20     

Jan thru       20     

Employment (including leased or temporary workers) associated with this article

Number of workers reported age 50 or over (including leased or temporary workers) associated with this article

Total Sales (This location only)

Dollars Quantity*

Production (This location only)

Dollars Quantity*

U.S. Exports (This location only)

Dollars Quantity*

U.S. Imports Firm-wide (Including Like or Directly Competitive Articles)

Dollars Quantity*

U.S. Imports Firm-wide of Finished Articles Incorporating U.S. Manufactured Components Like or Directly Competitive with the Article Identified Above

Dollars Quantity*

U.S. Imports Firm-wide of Finished Articles Incorporating non-U.S. Manufactured Components Like or Directly Competitive with the Article Identified Above

Dollars Quantity*

Production Shifted by the Subject Firm or Parent Company From this Location to Foreign Countries

Dollars Quantity*

List countries where imports originated:

List countries to which production was shifted:

*Quantities provided are measured in:

(For example: units, dozens, pounds, tons)

Numbers shown are actual or estimates?

C. Secondary Impact
Does the subject firm conduct business with a firm whose workers have been certified under the TAA program? Yes  No 
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 article produced by the subject firm at this location, provide a list of the subject firm’s customers that account for the majority of the decline in sales of the article 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. Reproduce and attach additional sheet(s) as necessary.
Identify article:

CUSTOMERS:

20     

20     

Jan thru       20     

Jan thru       20     

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Tel:

Fax:

Email:

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Tel:

Fax:

Email:

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Tel:

Fax:

Email:

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Tel:

Fax:

Email:

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Tel:

Fax:

Email:

Company Name:

Dollars

Address:

Contact/Buyer:

Quantity*

Tel:

Fax:

Email:

*Quantities provided are measured in:

(For example: units, dozens, pounds, tons)

E. LOST BIDS / CONTRACTS FOR ARTICLES

Has your firm lost bids for contracts to supply the articles produced by the 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:

Product:

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:

Product:

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:

Product:

ID#:

Address:

Amount of Bid:

Quantity:

Date of Award:

Contracting Agent:

Awardee (If Known):

Phone/Fax:

Period Of Performance:

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

Please provide contact information for individuals who may be contacted with follow-up questions regarding Part I or Part II, 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

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

ETA-9043a (Rev. 10/11) Previous forms not usable