ETA-8562A2 Business Customer Survey

EMPLOYMENT AND TRAINING ADMINISTRATION

UNITED STATES DEPARTMENT OF LABOR

OMB Control No.: 1205-0342
Expiration Date: 09/30/2022

Compliance Date: [DATE]

BUSINESS CUSTOMER SURVEY

PETITION NUMBER: TA-W-[NUMBER]

WORKERS’ FIRM NAME: [NAME OF WORKER GROUP]

WORKERS’ FIRM LOCATION: [FULL ADDRESS]

CUSTOMER NAME AND FULL ADDRESS: [CUSTOMER NAME], [ADDRESS]

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

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

Processing Instructions

A petition for Trade Adjustment Assistance (TAA) and Alternative Trade Adjustment Assistance (ATAA) 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)), 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 to apply for federal benefits. Complete and return this form no later than [Insert date here].

Background. The Trade Adjustment Assistance (TAA) and Alternative Trade Adjustment Assistance (ATAA) for Workers program (TAA/ATAA 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/ATAA program offers the following services to eligible workers: employment and case management services, training, out of area job search and relocation allowances, income support, as well as, additional benefits for workers age 50 or older to find reemployment and additional support. Filing a petition is the first step in qualifying for TAA/ATAA 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/ATAA 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 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), 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: _______ 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/ATAA 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 CUSTOMER OFFICIAL:

TITLE:

SIGNATURE: DATE:

BUSINESS ADDRESS:

E-MAIL ADDRESS:

PHONE NUMBER: ALTERNATIVE NUMBER:

Part I

1. Report your total purchases of [ARTICLE] from the workers’ firm, other firms located in the United States, and imports, for the periods identified in the table below. Include like or directly competitive articles. If there are no purchases reported, enter “zero,” “0,” or “None.” If more than one article is purchased from the workers’ firm, provide additional sheets as needed. Estimates are acceptable.

[ARTICLE OR SERVICE]
	Purchases from the Workers’ Firm		U.S. Import Purchases (direct imports)		Purchases from Firms within the U.S. of Products Wholly Manufactured in a Foreign Country (indirect imports)
	Quantity	Dollars	Quantity	Dollars	Quantity	Dollars
[DATE] to [DATE]
[DATE] to [DATE]

Measurement in which quantities are provided:
(Example: units, kilograms, pounds, tons, etc.)
List country(s) where direct imports originated:
List country(s)where indirect imports originated:

2. If your purchases from the workers’ firm have declined from [DATE] to [DATE] through [DATE] to [DATE], explain why:

Explain how you utilized [ARTICLE] purchased by the workers’ firm during the period of [DATE] to [DATE] and [DATE] to [DATE].
Part II

1. Identify the article(s) into which you directly incorporated the component article(s), as applicable, (identified within Part I, 1.) purchased from the workers’ firm:
2. Identify all U.S. facilities, including yours, during the periods of [DATE] to [DATE] and [DATE] to [DATE], which produced articles incorporating [ARTICLE] purchased from the workers’ firm. Provide name and address of each facility (including affiliates of your firm, if applicable), if known.
3. 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, 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, etc.)

Page 2 ETA-8562A – Business Customer Survey

For more information, visit our website at www.dol.gov/agencies/eta/tradeact/ Revision Date: 7/2021