ETA-8562a Business Customer Survey

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

OMB # 1205-0342 Exp. 1/31/2013 Business Confidential Customer Survey 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 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. 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 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, Office of Trade Adjustment Assistance, 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) 693-3584 or (202) 693-3585
Name of Customer and Location:

Part I

1. Report for the article 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 Other Firms Located in the U.S.			Imports into the U.S.
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 domestic purchases originating in foreign countries, if known:
20   :	______%	20  :	______%	Jan thru       20     :	______%	Jan thru       20    :	______%

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) 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.

Part II

5. Identify the article(s) into which your firm directly incorporates the components purchased from the subject firm: __________________________________________________________
6. List all U.S. facilities of your firm, which produce articles incorporating components or services purchased from the subject firm:
7. Is your company switching from purchasing articles from the subject firm to purchasing articles or services from a supplier outside the U.S.? Yes  No 
\
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):

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.

								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.)

Part III

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 (Rev.10/11) Previous forms not usable