Form ETA 9118 ETA 9118 ETA 9118

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

OMB # 1205-0342 (Exp. 8/31/2019) Business Information Request Compliance Date:

Processing Instructions

A petition for Trade Adjustment Assistance (TAA) 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 USC 2273(a)). The Secretary of Labor is authorized to obtain this information through subpoena if you fail to comply with this request (19 USC 2272(d)(3)(B) and 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 petition, the U.S. Department of Labor must investigate and 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 the worker group is 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. 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 only 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), 29 CFR Parts 70 and 90, Executive Order 12600, dated June 23, 1987 (352 FR 23781, June 25, 1987), Executive Order 13392, dated December 14, 2005 (70 FR 75373, December 19, 2005); Presidential Memorandum for the Heads of Executive Departments and Agencies Concerning the Freedom of Information Act (74 FR 4683, January 21, 2009); and Attorney General Holder's Memorandum for Heads of Executive Departments and Agencies Concerning the Freedom of Information Act (March 19, 2009), available at http://www.usdoj.gov/ag/foia-memo-march2009.pdf..

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 2272(d)(3)(B) and 2321). Public reporting burden for this collection is estimated to average 1 hour 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-     
Employing 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
Job Site Firm and Location:	     

I. Are / were [employing firm] workers performing work under contract for [job site firm] during [“relevant time period”- period of investigation]? Yes  No 

1. If “No”, proceed to and complete the Affirmation of Information section.

2. If “Yes”, is / was work done by the workers performed on-site at [job site firm]? Yes  No 

3. Please describe the job functions that [employing firm] workers perform for [job site firm]:

II. To determine whether workers are under the control of [job site firm], please respond to the questions below and explain your answers in the space provided or on a separate sheet.

1. Do the contract workers perform only tasks that are independent, discrete projects for [job site firm] (as opposed to performing tasks that are part of the regular business operations of [job site firm])?

Yes  No 

2. (a) Does [job site firm] have the discretion to hire, fire, and discipline the contract workers? Yes  No 

(b) Does [job site firm] have the ability to terminate the contract workers’ employment with [job site firm] through [employing firm]? Yes  No 

3. Does [job site firm] exercise the authority to supervise the contract workers’ daily work activities, including assigning and managing work, and determining how, where, and when the work of individual workers takes place? (Factors such as the hours of work, the selection of work, and the manner in which the work is to be performed by each individual are relevant.) Yes  No 

4. Are the services of the contract workers offered on the open market? Yes  No 

5. Do the contract workers work exclusively for [job site firm]? Yes  No 

6. Is [job site firm] responsible for establishing wage rates and the payment of salaries to individual contract workers? Yes  No 

7. Does [job site firm] provide skills training to the contract workers? Yes  No 

8) Are there other facts indicating that [job site firm] exercises control over the contract workers? Please explain:

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 in this form 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-9118 (Rev. 3/13) Previous forms not usable