| Trade Adjustment Assistance (TAA) Program |
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U.S. Department of Labor |
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| Reserve Funding Request Form |
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Employment and Training Administration |
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OMB Approval No. 1205-0275 |
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Expiration Date: 05/31/2016 |
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| 1. State: |
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3. Total Amount of Funds Requested: |
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a. Training: |
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| 2. Report Period Ending: |
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b. Job Search/Relocation: |
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| 4. FINANCIAL DATA: (Complete for each relevant fiscal year allocation) |
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| Fiscal Year : Period Covered by this Report (Month, Day, Year): From: To: |
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Job Search |
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Program |
Grand |
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Admin |
Relocation |
Training |
Total |
Total |
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(2 + 3) |
(1 + 4) |
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(1) |
(2) |
(3) |
(4) |
(5) |
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| A. TAA Funds Received to Date |
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$- |
$- |
| B. Cumulative Obligations |
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$- |
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$- |
$- |
| C. Unobligated Balance |
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$- |
$- |
$- |
$- |
$- |
| D. Cumulative Accrued Expenditures |
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$- |
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$- |
$- |
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| Fiscal Year : Period Covered by this Report (Month, Day, Year): From: To: |
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Job Search |
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Program |
Grand |
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Admin |
Relocation |
Training |
Total |
Total |
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(2 + 3) |
(1 + 4) |
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(1) |
(2) |
(3) |
(4) |
(5) |
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| A. TAA Funds Received to Date |
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$- |
$- |
| B. Cumulative Obligations |
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$- |
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$- |
$- |
| C. Unobligated Balance |
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$- |
$- |
$- |
$- |
$- |
| D. Cumulative Accrued Expenditures |
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$- |
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$- |
$- |
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| Fiscal Year : Period Covered by this Report (Month, Day, Year): From: To: |
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Job Search |
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Program |
Grand |
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Admin |
Relocation |
Training |
Total |
Total |
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(2 + 3) |
(1 + 4) |
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(1) |
(2) |
(3) |
(4) |
(5) |
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| A. TAA Funds Received to Date |
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$- |
$- |
| B. Cumulative Obligations |
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$- |
$- |
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$- |
$- |
| C. Unobligated Balance |
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$- |
$- |
$- |
$- |
$- |
| D. Cumulative Accrued Expenditures |
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$- |
$- |
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$- |
$- |
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Page 1 of 2 |
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ETA-9117 |
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(Dec. 2003) |
| Trade Adjustment Assistance (TAA) Program |
| Reserve Funding Request Form |
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| 5. JUSTIFICATION FOR REQUEST: |
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| CERTIFICATION: I certify that to the best of my knowledge and belief that the information provided herein is |
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| accurate and complete, and that report obligations are reflected in agency records. |
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| Signature: |
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Title: |
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Date: |
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| Persons are not required to respond to this collection of information unless it displays a currently valid OMB |
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| control number. Public reporting burden for this collection of information is estimated to average 2 hours per |
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| response including the time for reviewing instructions, searching existing data sources, gathering and maintaining |
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| the data needed, and completing and reviewing the collection of information. [Respondent's obligation to respond |
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| are required to obtain or retain benefits (Trade Adjustment Assistance Reform Act of 2002)] Send comments |
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| regarding this burden estimate or any other aspect of this collection of information, including suggestions for |
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| reducing this burden to the U.S. Department of Labor, Division of Trade Adjustment Assistance, Room C-5311, |
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| Washington, D.C. 20210 (Paperwork Reduction Project 1205-0275). |
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Page 2 of 2 |
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ETA-9117 |
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(Dec. 2003) |