Form ETA-9043 Business Data Request

OMB Control Number: 1205-0342

EMPLOYMENT AND TRAINING ADMINISTRATION

UNITED STATEES DEPARTMENT OF LABOR

Expiration Date: X/XX/XXXX

Compliance Date: [DATE]

BUSINESS DATA REQUEST

PETITION NUMBER: TA-W-[NUMBER]

WORKERS’ FIRM NAME: [NAME OF WORKER GROUP]

WORKERS’ FIRM LOCATION: [FULL ADDRESS]

Contact the U.S. Department of Labor: [INVESTIGATOR NAME] – Email: [EMAIL]@dol.gov

Phone: 202-693-[XXXX] – Fax: 202-693-3986/3585/3584

Instructions for Completing this Form

A petition for Trade Adjustment Assistance (TAA) for Workers has been filed on behalf of a group of workers at [WORKERS’ FIRM NAME], [CITY], [STATE]. By law (19 U.S.C. 2273(a)), a determination on the petition must be made within 40 calendar days following the filing date of the petition. The Secretary of Labor is authorized to obtain the information requested in this survey through subpoena if the firm fails to comply with this request (19 U.S.C. 2272(d)(3)(B) and 2321). Your assistance in expeditiously completing this form is necessary for the U.S. Department of Labor (Department) to determine whether these workers may be eligible to apply for federal benefits. Complete and return this form no later than [Insert date here].

Background. The TAA for Workers program (TAA Program) is authorized under Title II of the Trade Act of 1974, as amended (19 U.S.C. § 2271 et seq.) (“the Act”). The TAA Program provides workers who have been adversely affected by foreign trade with opportunities to obtain skills, credentials, resources, and support necessary to become reemployed. The TAA Program offers the following services to eligible workers: employment and case management services, training, out of area job search and relocation allowances, income support through Trade Readjustment Allowances (TRA), and the Reemployment Trade Adjustment Assistance (RTAA) benefit for workers age 50 or older who find qualifying reemployment. Filing a petition is the first step in qualifying for TAA Program benefits and services. In response to a filing, the Department conducts an investigation to determine whether foreign trade was an important cause of the workers’ job loss or threat of job separation. After the investigation, the Department issues a determination regarding the worker group’s eligibility to apply for TAA Program benefits and services. A state workforce representative will notify workers in a certified worker group of the determination, at which time the individual worker may apply for eligibility of benefits and services at a local American Job Center. Additional information is available on our website at www.dol.gov/agencies/eta/tradeact/.

Completing Form. Individuals are only required to respond to this information request if the form displays a valid Office of Management and Budget (OMB) control number. Type or print legibly and complete all sections. If there is no quantity or value for a field in a section on this form, enter “zero,” “0,” or “None” Include any relevant information not covered in this form on a separate sheet of paper and/or attach other supporting documents when submitting this form to the Department. If you have any difficulty completing this form, or have questions, 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 the petition have been satisfied.  The Department will protect the confidentiality of the information you provide to the full extent of the law, in accordance with the Act, 19 U.S.C. 2272 (d)(3)(C); the Trade Secrets Act, 18 U.S.C. 1905; the Freedom of Information Act, 5 U.S.C. 552(b)(4); Executive Order 12600 (52 F.R. 23781, June 25, 1987); Executive Order 13392 (70 F.R. 75373, December 19, 2005);  Presidential Memorandum for the Heads of Executive Departments and Agencies Concerning the Freedom of Information Act (74 F.R. 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 https://www.usdoj.gov/ag/foia-memo-march2009.pdf. Information (on the form and attachments) which your firm would like to be considered as confidential must be placed in brackets and accompanied with a justification for such designation.

Public Burden Statement. This collection of information is mandatory (19 U.S.C. 2272(d)(3)(B) and 2321). Public reporting burden for this collection is estimated to average 4 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).

Report the number of hours and costs to your firm for completing this form.

Hours: ________ Cost in Dollars: ____________________

Affirmation of Information

A qualified representative of your firm is required to complete this request because a petition for a determination of eligibility to apply for TAA benefits and services has been filed on behalf of workers employed or previously employed by your firm.

Information from the firm is needed in order to determine if the worker group can be certified as having been impacted by foreign trade under the Act. Knowingly making a false statement of a material fact, knowing it to be false or knowingly failing to disclose a material fact on this form, is a Federal offense (19 U.S.C. § 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 on this form is true, correct, and complete.”

NAME OF COMPANY OFFICIAL: _____________________________________________________________________

TITLE: ________________________________________________________________________________

SIGNATURE: ___________________________________________ DATE: ______________________

BUSINESS ADDRESS: _________________________________________________________________________________

E-MAIL ADDRESS: __________________________________________________________

PHONE NUMBER: ______________________________ ALTERNATE NUMBER: ____________________________

Additional Company Contacts

Provide contact information for individuals who may be contacted with supplemental questions, if different from the company official signing the affirmation.

			Primary Contact 1		Primary Contact 2
a) a)	Name of Company Official
b)	Title
c)	Business Address
d)	E-mail Address
e)	Phone Number
f)	Alternative Number

Part I

FIRM INFORMATION Provide the official name of the firm and its location (the subject of the investigation). Any corrections or clarification to the group articulated within the header should be reconciled here.
(1) Workers’ Firm Name:				Department and/or Division
	Address:
	Website:

(2) Provide the names and addresses of all companies supplying staffed workers to supplement the firm’s workforce during the period from [DATE] to [DATE], describe their functions, and identify whether the staffed workers performed these functions on-site or off-site.

(3) Since [DATE], have the workers’ wages been reported under another corporate name? Yes  No 
	(a) If Yes, explain why:
	(b) Provide the corporate name(s) under which their wages were reported:

B. ORGANIZATIONAL STRUCTURE

1. Describe the organizational structure of the workers’ firm, including, but not limited to, the parent company, affiliates and subsidiaries.

(Attach any existing diagrams of organizational structure and any website address providing information on the organizational structure.)

2. If there are other subdivision(s) within the firm manufacturing articles and/or supplying services that are like or directly competitive with the articles manufactured and/or services supplied where the subject workers are/were employed, provide a list of location(s), including the city, state, and country, where these activities are performed.

C. ACTIVITIES OF THE WORKERS’ FIRM (1) Check the box identifying whether the parent company is in the manufacturing sector or service sector. Article Producer/Manufacturer  Service Sector Firm  Specify the nature of the firm’s outputs based upon the response to Part I C.(1). (Example: engines, publishing services, leasing agency, etc.)
(3) Provide a detailed description of the activities performed by the workers’ firm identified within Part I A.(1) (i.e., whether the workers are engaged in activities related the production of an article or the supply of a service) and provide specifics regarding what articles are produced or service is supplied, as applicable.
Who are the direct-users of the activities performed by the workers’ firm and what is the next step in production, if any?
Explain how the activities of the worker’s firm intersect with the nature of the parent company’s business(i.e., does the workers’ firm supply services in support of production for the parent compay, does the workers’ firm produce a component for the parent company, does the workers’ firm supply transportation services for the company company?)
What is the relationship between the workers’ firm and the affiliated entities/locations (identified within Part I B.(2)?
(7) Identify the North American Industry Classification System (NAICS) code(s) for the workers’ firm and the Harmonized Tariff Schedule (HTS) code for the articles produced, if known. Refer to the following websites: NAICS: https://www.census.gov/eos/www/naics/ and HTS: https://hts.usitc.gov/.
Does any part of the workers’ firm engage in any of the following activities related to the oil and gas industry: Oilfield and Natural Gas Drilling, Oilfield and Natural Gas Pumpers, Oilfield and Natural Gas Seismic and Geological Services, Oilfield and Natural Gas Mud Services? Yes  No 
(9) Are the outputs identified within Part I C.(3) directly incorporated by the firm, an affiliated location, and/or the end-user/consumer? Yes  No 
If yes, identify the finished article(s), next stage of production, and the entity engaged in this next stage of production.
(10) If more than one article is produced or more than one service is supplied (as applicable) at the workers’ firm, are workers separately identifiable by activities performed? Yes  No  If yes, explain. (Examples – Workers are cross trained to produce articles A and Band do/can switch between operations, as needed or as scheduled; the workers are individually identified as workers who produce article A and workers who produce article B, and they are not interchangeable.)

Part II

1. PETITIONER’S ALLEGATION(S)

Address the allegation(s) made by petitioner(s). See attached petition.

Part III

1. EMPLOYMENT OF THE WORKERS’ FIRM

1. Provide the number of workers (including staffed and remote workers) employed by the workers’ firm (identified within Part I, A.1.) during the stated period of time identified in the table below.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(3)):

# of workers employed on [DATE]

2. How many workers (including staffed and remote workers) were separated (involuntary and voluntary) at the workers’ firm between [DATE] and [DATE]?

# of workers separated between [DATE] and [DATE]

3. Provide the number of worker separations (including staffed workers and remote workers) at the workers’ firm that are planned or expected after [DATE] below:

# of workers separated planned/expected between [DATE] and [DATE]

4. Have both wages and hours of workers (including staffed workers and remote workers) within the workers’ firm been reduced by at least 20% since [DATE]? Yes  No 

1. If yes, provide the number of workers that had their wages and hours reduced by at least 20% at the workers’ firm:

# of workers wages and hours reduced

5. Explain the reasons for these actual or expected separations and/or the 20% reduction in wages and hours. (Attach additional information and/or narratives as necessary.)

6. If you believe the effects of foreign trade have contributed importantly to these separations and/or to the 20% reduction in wages and hours, describe why. (Attach additional information and/or narratives as necessary.)

7. Have the activities of the workers within the workers’ firm totally ceased? Yes  No 

1. 
   

   If yes, date operations ceased: (b) Is the cessation of operations permanent? Yes  No 

Explain the reason(s) for the cessation of operations.

8. Has the facility shutdown? Yes  No 

(a) If yes, date of shutdown: ________________ (b) Is the shutdown permanent? Yes  No 

Explain the reason(s) for the shutdown.

2. SALES OF THE WORKERS’ FIRM

Report the workers’ firm’s sales data for the articles or services, as applicable (identified within Part I C.(3)) for the periods provided in the table. Below the table, provide the applicable unit of measurement. If more than one article is produced or service is supplied at this location, reproduce this page and complete the page for each article or service, as applicable.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(3)):

	[DATE] to [DATE]	[DATE] to [DATE]
Total Sales in US Dollar
Total Sales in Quantity

Measurement of quantities provided.(Example: units, kilograms, pounds, tons, hours

of work, value contract, number of phone calls, etc.)

3. PRODUCTION OF THE WORKERS’ FIRM

Report the workers’ firm’s production data for the articles or services, as applicable (identified within Part I C.(3)) for the periods provided within the table. Below the table, provide the applicable unit of measurement. If more than one article is produced or service is supplied at this location, reproduce this page and complete the page for each article or service, as applicable.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C. (3)):

	[DATE] to [DATE]	[DATE] to [DATE]
Total Production/Supply in US Dollar
Total Production/Supply in Quantity

Measurement of quantities provided. (Example: units, kilograms, pounds, tons, hours

of work, value contract, number of phone calls, etc.)

4. EXPORT SALES OF THE WORKERS’ FIRM

Report the workers’ firm’s export data for the articles or services, as applicable (identified within Part I C. (3)) for the periods provided within the table. Below the table, provide the applicable unit of measurement. If more than one article is produced or service is supplied at this location, reproduce this page and complete the page for each product or service, as applicable.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(3)):

	[DATE] to [DATE]	[DATE] to [DATE]
Total Exports in US Dollar
Total Exports in Quantity

Measurement of quantities provided. (Example: units, kilograms, pounds, tons, hours

of work, value contract, number of phone calls, etc.)

PART IV

1. IMPORTS OF THE FIRM

Report the import data for the articles or services, as applicable (identified within Part I C. (3)), as well as like or directly competitive articles or services, as applicable, by the firm (identified within Part I B.(1)) for the periods provided within the table. Below the table, provide the applicable unit of measurement. If more than one article is produced or service is supplied at this location, reproduce this page and complete the page for each product or service, as applicable.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(3)):

	[DATE] to [DATE]	[DATE] to [DATE]
Total Workers’ Firm Imports in US Dollar
Total Workers’ Firm Imports in Quantity
Total Firm-wide Imports in US Dollar
Total Firm-wide Imports in Quantity

Measurement of quantities provided: _____________________________

(Example: units, kilograms, pounds, tons, hours of work, value contract, number of phone calls, etc.)

Country(s) of import origination: ______________________________

2. FINISHED ARTICLE IMPORTS OF THE FIRM

Report the import data for finished articles (identified within Part I, C.(9)) containing components parts that are like or directly competitive with the articles identified within Part I, C.(3) by the firm or services supplied identified Part I, C.(3) in the production of the finished articles within for the periods provided within the table. Below the table, provide the applicable unit of measurement. If more than one article is produced or service is supplied at this location, reproduce this page and complete the page for each article or service, as applicable.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(9)):

	[DATE] to [DATE]	[DATE] to [DATE]
Total Workers’ Firm Imports of Finished Articles in US Dollar
Total Workers’ Firm Imports of Finished Articles in Quantity
Total Firm-wide Imports of Finished Articles in US Dollar
Total Firm-wide Imports of Finished Articles in Quantity

Measurement of quantities provided: _____________________________

(Example: units, kilograms, pounds, tons, hours of work, value contract, number of phone calls, etc.)

Country(s) of import origination: ______________________________

3. SHIFTS/CONTRACTING BY THE WORKERS’ FIRM

Report the non-import data for the firm’s articles or services, as applicable (identified within Part I C.(3)), as well as like or directly competitive articles or services by the firm (identified within Part I B(1)) for the periods provided within the table. Below the table, provide the applicable unit of measurement. Non-import data includes, but is not limited to, shift in production/operations to another country, shift in the supply of services to another country, contracting with another entity to have production occur in another country, contracting with another entity to have the supply of services occur in another country, and increasing reliance on existing operations in another country while decreasing reliance on existing domestic operations. If more than one article is produced or service is supplied at this location, reproduce this page and complete the page for each product or service, as applicable.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(3)):

	[DATE] to [DATE]	[DATE] to [DATE]
Shift in Production/Service in US Dollar
Shift in Production/Service in Quantity

Measurement of quantities provided: _____________________________

(Example: units, kilograms, pounds, tons, hours of work, value contract, number of phone calls, etc.)

Country(s) of import origination: ______________________________

1. Has the workers’ firm shifted activities such that the article will be produced or the service will be supplied outside the United States?

Yes  No 

1. If yes, provide the date of that the shift began/will begin:

2. 
   

   Describe the arrangement of the shift.(i.e, i.e. procurement of equipment, acquisition of a facility, signing of contracts, etc.)

	[DATE] to [DATE]	[DATE] to [DATE]
Acquisition of Production/Service in US Dollar
Acquisition of Production in Quantity

Measurement of quantities provided: _____________________________

(Example: units, kilograms, pounds, tons, hours of work, value contract, number of phone calls, etc.)

Country(s) of import origination: ______________________________

2. Has the workers’ firm contracted to have the article produced outside the United States? Yes  No 

1. 
   

   If yes, provide the date the contract began:

2. 
   

   Provide the date the contract ends:

3. Describe the arrangement of the contract. (i.e., where will the articles or services, as applicable, be provided?)

PART V

SALES TO CUSTOMERS

For each article or service, as applicable, identified within Part I, C.(3), produced/supplied by the workers’ firm (identified within Part I A), provide a list of reoccurring customers that each account for at least 20% of the workers’ firm’s sales.  Report the workers’ firm’s data for the period stated within the table.  Reproduce and attach additional sheet(s) as necessary. If the worker’s firm solely operates under a contract environment where revenue is generated by a bid-by-bid basis, skip this section and complete Part V, C.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(3)):

						[DATE] to [DATE]	[DATE] to [DATE]
(1) Customer Name:					Dollars
Ship to Address:
Customer Official:
Customer Official Address:
					Quantity
Phone:			Fax:
Email:

(2) Customer Name:					Dollars
Ship to Address:
Customer Official
Customer Official Address:					Quantity
Phone:			Fax:
Email:

(3) Customer Name:					Dollars
Ship to Address:
Customer Official
Customer Official Address:					Quantity
Phone:			Fax:
Email:

(4) Customer Name:

Dollars

Ship to Address:

Customer Official

Customer Official Address:

Quantity

Phone:

Fax:

Email:

(5) Customer Name:				Dollars
Ship to Address:
Customer Official
Customer Address:				Quantity
Phone:			Fax:
Email:

B. SALES TO CUSTOMERS

For each article or service, as applicable, identified within Part I, C.(3) produced/supplied by the workers’ firm, (identified within Part I A, provide a list of domestic customers which constitute reoccurring customers which represent the majority of the decline in workers’ firm’s sales. Report the workers’ firm’s data for the period stated within the table. Reproduce and attach additional sheet(s) as necessary.

If the worker’s firm operates solely under a contract environment where revenue is generated by a bid-by-bid basis, skip this section and complete Part V, C.

Identify Article(s) Produced or Service(s) Supplied (identified within Part I, C.(3)):

						[DATE] to [DATE]	[DATE] to [DATE]
(1) Customer Name:					Dollars
Ship to Address:
Customer Official:
Customer Official Address:
					Quantity
Phone:			Fax:
Email:

(2) Customer Name:					Dollars
Ship to Address:
Customer Official
Customer Official Address:					Quantity
Phone:			Fax:
Email:

(3) Customer Name:					Dollars
Ship to Address:
Customer Official
Customer Official Address:					Quantity
Phone:			Fax:
Email:

(4) Customer Name:					Dollars
Ship to Address:
Customer Official
Customer Official Address:					Quantity
Phone:			Fax:
Email:

(5) Customer Name:				Dollars
Ship to Address:
Customer Official
Customer Official Address:				Quantity
Phone:			Fax:
Email:

C. LOST BIDS / CONTRACTS

Did the workers’ firm lose bids for contracts to produce articles or supply services, identified within Part I, C(3), during the period from [DATE] to [DATE]? Yes  No 

If yes, list the major projects for which the workers’ firm submitted unsuccessful bids during the period referenced above. Reproduce and attach sheet(s), if needed, to provide information for major contracts lost.

(1) Contracting Firm:

Project Manager Name:

Address:

Phone:

Fax:

Email:

Website:

Project Identification:

Project Description:

Amount of Bid:

Period of Performance:

Date of Award:

Awardee (if known):

(2) Contracting Firm:
Project Manager Name:
Address:
Phone:		Fax:	Email:
Website:
Project Identification:
Project Description:
Amount of Bid:		Period of Performance:		Date of Award:
Awardee (if known):

(3) Contracting Firm:

Project Manager Name:

Address:

Phone:

Fax:

Email:

Website:

Project Identification:

Project Description:

Amount of Bid:

Period of Performance:

Date of Award:

Awardee (if known):

(4) Contracting Firm:
Project Manager Name:
Address:
Phone:				Fax:	Email:
Website:
Project Identification:
Project Description:
Amount of Bid:			Period of Performance:			Date of Award:
Awardee (if known):

Page 18 ETA-9043 – Business Data Request

For more information, visit our website at www.dol.gov/agencies/eta/tradeact/ Revision Date: 9/2020