Form ETA-9117 Trade Adjustment Assistance (TAA) Program Funding Reques

U .S. Department of Labor OMB Control Number: 1205-0275

Employment and Training Administration Expiration Date: XX/XX/XXXX Office of Trade Adjustment Assistance

Trade Adjustment Assistance (TAA) for Workers

Funding Request Form

1. STATE: 2. AMOUNT REQUESTED: __________________________

3. FINANCIAL DATA: (Complete for each relevant fiscal year allocation)

Fiscal Year: _____ Period Covered by this Report (MM/DD/YYYY) From: _____________ To: _______________

	(1) Administrative Costs	(2) Employment and Case Management	(3) Training and Related Costs	(4) Program Total (2 + 3)	(5) Grand Total (1 + 4)
A. TAA Funds Received to Date					$
B. Cumulative Obligations	$	$	$	$	$
C. Unobligated Balance (A-B)	$	$	$	$	$
D. Cumulative Accrued Expenditures	$	$	$	$	$
E. Utilization Percentages	% (D1/A5)	% (D2/A5)

Fiscal Year: _____ Period Covered by this Report (MM/DD/YYYY) From: _____________ To: _______________

	(1) Administrative Costs	(2) Employment and Case Management	(3) Training and Related Costs	(4) Program Total (2 + 3)	(5) Grand Total (1 + 4)
A. TAA Funds Received to Date					$
B. Cumulative Obligations	$	$	$	$	$
C. Unobligated Balance (A-B)	$	$	$	$	$
D. Cumulative Accrued Expenditures	$	$	$	$	$
E. Utilization Percentages	% (D1/A5)	% (D2/A5)

Fiscal Year: _____ Period Covered by this Report (MM/DD/YYYY) From: _____________ To: _______________

		(1) Administrative Costs	(2) Employment and Case Management	(3) Training and Related Costs	(4) Program Total (2 + 3)	(5) Grand Total (1 + 4)
	A. TAA Funds Received to Date					$
	B. Cumulative Obligations	$	$	$	$	$
	C. Unobligated Balance (A-B)	$	$	$	$	$
	D. Cumulative Accrued Expenditures	$	$	$	$	$
	E. Utilization Percentages	% (D1/A5)	% (D2/A5)
4. JUSTIFICATION FOR REQUEST:

Certification: I certify that to the best of my knowledge and belief that the information provided herein is accurate and complete, and that report obligations are reflected in agency records.

Signature: ______________________________________ Title:___________________________________

Date: ______________________

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. Public reporting burden for this collection is estimated to average 2 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: U.S. Department of Labor, Employment and Training Administration, Office of Trade Adjustment Assistance, Room N-5428, 200 Constitution Avenue, N.W., Washington, DC 20210 (OMB Control No. 1205-0275).

Page 4 of 4 For more information, visit our website at https://www.doleta.gov/tradeact ETA-9117

Revision Date: 7/2019