ETA-8562a-1 Business Second Tier Customer Survey

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

OMB # 1205-0342 Exp. 1/31/2013 Business Confidential Second Tier 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]. 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. 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 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-     

Contact at the U.S. Department of Labor:	     	E-Mail:     @dol.gov
	Phone: (202) 693-      Fax: (202) 693-3986 or (202) 693-3584 or (202) 693-3585
Name of Customer and Location:	     

1. Report for the article below your total purchase from U.S. firms and non-U.S. firms 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”.

Article: [Finished Article]

	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, pounds, kilograms, tons) :

2. For U.S. Purchases (identified 85 in Question 1), 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     	%
List countries:

3. If known, did your firm purchase any Non-U.S.-manufactured [finished articles] that incorporate non U.S.-manufactured [subject firm component parts]? Yes  No 
a) If “Yes”, indicate percentage of Non-U.S.-manufactured [finished articles] incorporating non U.S.-manufactured [subject firm component parts].
20     	%	20     	%	Jan thru       20     	%	Jan thru       20     	%
List countries:

Numbers shown are 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:

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

ETA-8562a-1 (Rev. 10/11) Previous forms not usable