ETA-8562A3 Business Customer Survey -- Anonymous

EMPLOYMENT AND TRAINING ADMINISTRATION

UNITED STATEES DEPARTMENT OF LABOR

OMB Control Number: 1205-0342

Expiration Date: XX/XX/20XX

Compliance Date: [DATE]

BUSINESS CUSTOMER SURVEY - ANONYMOUS

PETITION NUMBER: TA-W-[ANONYMOUS]

WORKERS’ FIRM NAME: [ANONYMOUS]

WORKERS’ FIRM LOCATION: [ANONYMOUS]

CUSTOMER NAME, ADDRESS: [CUSTOMER NAME], [ADDRESS]

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

Phone: 202-693-[XXXX] – Fax: 202-693-3986/3985/3984

Processing Instructions

A petition for Trade Adjustment Assistance (TAA) for Workers has been filed on behalf of a group of workers at a firm. By law (19 U.S.C. 2273(a)), this determination must be made within a 40 calendar days following the filing date of the petition. The Secretary of Labor is authorized to obtain this information 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 (the Department) to determine whether these workers may be eligible 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 benefits and 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 determines worker group 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. For a worker to be eligible to apply for individual eligibility, the worker must be part of a group of workers that is the subject of a petition filed with the Department. 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 a 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), Trade Secrets Act, 18 U.S.C. 1905 and the Freedom of Information Act, 5 U.S.C. 552(b)(4), 20 CFR Part 618, Executive Order 12600, dated June 23, 1987 (352 F.R. 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 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 2.5 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: ____ Costs in Dollars: ________________

Affirmation of Information

The information you provide on this form is used by the Department to determine worker group eligibility and to estimate the total number of workers covered by the petition. Knowingly falsifying any information on this form is a Federal offense (18 U.S.C. § 1001) and a violation of the Act (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 CUSTOMER OFFICIAL: _____________________________________________________________________

TITLE: ________________________________________________________________________________

SIGNATURE: ___________________________________________ DATE: ______________________

BUSINESS ADDRESS: _________________________________________________________________________________

E-MAIL ADDRESS: __________________________________________________________

PHONE NUMBER: ______________________________ ALTERNATE NUMBER: ____________________________

Part I

1. Report your total purchases of [ARTICLE OR SERVICE] from firms manufacturing articles or supplying services in the United States and firms located outside of the United States for the periods identified in the table below. Include like or directly competitive articles or services. If there are no purchases enter “zero,” “0,” or “None.” Estimates are acceptable.

[ARTICLE PRODUCED/SERVICE SUPPLIED]

Purchases from Firms Manufacturing Articles or Supplying Services in the U.S.

U.S. Import Purchases (direct imports)

Purchases from Firms in the U.S. in which Products were Wholly Manufactured/Services were Wholly Supplied in a Foreign Country (indirect imports)

Quantity

Dollar

Quantity

Dollars

Quantity

Dollars

[DATE] to [DATE]

[DATE] to [DATE]

Measurement in which quantities are provided:
(Example: units, kilograms, pounds, tons, hours of work, value of contract, number of phone calls, etc.)
List countries where direct imports originated:
List countries where indirect imports originated:

2. If your purchases from firms manufacturing articles or supplying services within the U.S. have declined during [DATE] to [DATE] or [DATE] to [DATE], explain why:
Explain how you utilized [ARTICLE OR SERVICE] purchased by firms manufacturing articles or supplying services within the U.S. during the period of [DATE] to [DATE] and [DATE] to [DATE].

Part II

1. Identify the article(s) or service(s) into which you directly incorporated the component article(s)or utilized service(s) supplied, as applicable (identified within Part I, 1.), purchased from firms manufacturing within the United States.
2. Identify all U.S. facilities, including yours, during the periods of [DATE] to [DATE] and [DATE] to [DATE], which produced articles incorporating [ARTICLE] or supplied services utilizing [SERVICE], as applicable, purchased from the firms manufacturing within the United States. Provide name and address of each facility (including affiliates of your firm, if applicable).
3. FOR ARTICLE PRODUCERS ONLY: For each article identified in Part II, 1 provide the information requested in the table below for the facilities identified within Part II, 2. If there are no quantities or dollar values, enter “zero,” “0,” or “None.”
		[DATE] to [DATE]	[DATE] to [DATE]
Total Sales	Dollars
Total Production	Quantity
Firm’s U.S. Imports which contain U.S. manufactured [ARTICLE PRODUCED]	Dollars
	Quantity
Firm’s U.S. Imports which contain non-U.S. manufactured [ARTICLE PRODUCED]	Dollars
	Quantity

Measurement in which quantities are provided:
(Example: units, kilograms, pounds, tons, hours of work, value of contract, number of phone calls, etc.)
List countries where U.S. imports originated:

4. If you reported declining sales or production for the periods identified within Part II, 3, provide a list of your firm’s declining customers that account for the majority of your sales or production decline. Reproduce and attach additional sheets as necessary.

						[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:

Measurement in which quantities are provided:
(Example: units, kilograms, pounds, tons, hours of work, value of contract, number of phone calls, etc.)
List countries where U.S. imports originated:

Page 6 ETA-8562A-3 – Business Customer Survey - Anonymous

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