ETA 9042 Petition

U .S. Department of Labor Employment and Training Administration OMB No. 1205-0342

Expires: 1/31/2013

Petition for Trade Adjustment Assistance (TAA)

About the Trade Adjustment Assistance (TAA) Program

The Trade Act of 1974 (19 USC § 2271 et seq.), as amended, established Trade Adjustment Assistance (TAA) to provide assistance to workers in firms hurt by foreign trade. Program benefits include long-term training while receiving income support. TAA provides both rapid and early assistance. Filing this petition is the first step in qualifying for TAA benefits and assistance. After the petition is filed, the U.S. Department of Labor will determine whether a significant number or proportion of the workers of the firm have become total or partially separated or are threatened to become totally or partially separated, and whether imports or a shift in production or services to a foreign country contributed importantly to these actual or threatened separations and to a decline in sales or in production of articles or supply of services. If a petition is approved and the 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 benefits. These benefits are provided at no expense to employers.

Filing Instructions

• A group of three workers from the same firm, a union official, a state or local workforce agency representative in a local American Job Center (also known as a One-Stop Career Center or by a different name), an employer official, or a legally authorized representative must complete this Petition Form by answering all questions before submitting to the U.S. Department of Labor.

• You must date and submit the Petition Form within 1 YEAR from the date on which the workers were separated or had their hours and wages reduced.

• You must file the Petition Form with both the U.S. Department of Labor in Washington, DC and the State TAA Coordinator or the dislocated worker office of the state where the firm is located. To file with both the U.S. Department of Labor and the State TAA Coordinator, electronically file the Petition Form on-line at http://www.etareports.doleta.gov/petition.

To file with the U.S. Department of Labor, use one of the methods below:

Fax the completed Petition Form to 202-693-3585, OR

Mail the completed Petition Form to the U.S. Department of Labor at:

U.S. Department of Labor

Office of Trade Adjustment Assistance

200 Constitution Ave NW, Room N-5428

Washington, DC 20210

To file with the State TAA Coordinator or the State Dislocated Worker Unit or State Workforce Agency

Use the contact information below to find the appropriate filing address. If this Petition Form includes locations in different states, copies of this completed Petition Form must be filed in each state where firms are located.

Toll-Free Helpline: 1-877-US2-JOBS (TTY) 1-877-889-5627

Internet: http://www.doleta.gov/tradeact/contacts.cfm#State, or

http://www.servicelocator.org

For assistance in preparing a petition

Petitioners may receive assistance in preparing the petition at their local American Job Center, by contacting the U.S. Department of Labor in Washington, D.C. at 202-693-3560 (Main Number), or by contacting their State Dislocated Worker Unit or State Workforce Agency through the telephone numbers or internet addresses provided above (29 CFR Part 90.11).

To check petition status

To check the status of your petition, please visit:

http://www.doleta.gov/tradeact/

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 required to obtain or maintain benefits (19 USC 2321 and 2271). Public reporting burden for this collection is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information, and a state review. 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 at the address provided above (Paperwork Reduction Project 1205-0342).

Section 1. Petitioner Information

Provide petitioner information below. Three workers from the same firm completing this Petition Form must fill in all three columns. Other petitioners need only fill in the Petitioner 1 column. A union official completing this petition form should provide the name of the Union.

		Petitioner 1		Petitioner 2		Petitioner 3
a)	Name
b)	Title
c)	Street Address
	City
	State, Zip
d)	Phone – Main
e)	Phone – Alternate
f)	E-mail
g)	Worker Separation Date

h)		Petitioner Type:	Three Workers 	Company Official 		Union Official  (Union Name_______)
		(please check one)	State Workforce Office 	American Job Center 		Other Authorized Representative 
i)	Describe the worker group on whose behalf this petition is being filed:

Section 2. Workers’ Firm

Provide information on the firm employing the worker group. Complete items (a) – (g) regarding the employing firm. If the workers are doing work at a location that is different than the worker’s employer (e.g., the petitioning workers are employed by a staffing agency but work at a manufacturing firm), also complete items (h) – (m) regarding the firm at which the workers perform their jobs.

NOTE: Workers completing this Petition Form must provide information for the location where they work. All other petitioner types may apply on behalf of more than one location. State offices and American Job Centers may file for workers at multiple locations of a firm within their State. If you choose to file on behalf of workers at more than one location, please attach additional sheets as necessary.

Employer (Firm)
a)	Name of Firm
b)	Street Address
	City
	State, Zip
c)	Phone
d)	Website (if known)
e)	Describe the article produced or service supplied by this firm
f)	How many workers have been or may be separated (if known)?
g)	Is the firm or any part of the firm closing (if known)? If yes, when?
If the workers work at a location that is different from that listed in item a) and b), then fill out items h) through m) for that location:
h)	Name of Firm
i)	Street Address
	City
	State, Zip
j)	Phone
k)	Describe the article produced or service supplied by this firm
l)	How many workers have been or may be separated (if known)?
m)	Is the firm or any part of the firm closing (if known)? If yes, when?

Section 3. Trade Effects on Separations

1. To the best of your knowledge, provide reasons why you believe that separations that have occurred or may be threatened at the workers’ firm are due to foreign trade. (Example: Production has been/is being shifted to a foreign country, services are being outsourced to a foreign country, increased imports of articles or services, loss of business with a TAA-certified firm.)

2. If you possess any additional information or documents that you believe may assist in the determination of whether the worker group is eligible for TAA benefits, submit it as an attachment to the Petition Form. Check the box below if you have attached any additional information or supporting documents.

I have attached additional information or supporting documents.

3. Provide contact information for two company officials, one of whom should be a dislocated worker’s supervisor. Either separately or together, these officials should be familiar with all of the following: employment, job functions, and sales or production at each job location.

		Official 1		Official 2
a)	Name
b)	Title
c)	Phone – Main
d)	Phone – Alternate
e)	Fax
f)	E-mail

Section 4. Affirmation of Information

The information you provide on this petition form will be used for the purposes of determining worker group eligibility and providing notice to petitioners, workers, and the general public that the petition has been filed and whether the worker group is eligible. Knowingly falsifying any information on this Petition Form is a Federal offense (18 USC § 1001) and a violation of the Trade Act (19 USC § 2316). For this petition to be valid, each of the petitioners listed in Question 1 must sign below and the Petition Form must be dated. By signing below, you agree to the following statements:

“I declare that to the best of my knowledge and belief the information I have provided is true, correct, and complete.”

a)	Signature
b)	Name (Print)
c)	Date of Petition

P age 3 of 3 For more information, visit our Web site at http://www.doleta.gov/tradeact ETA-9042

Rev. October 2011