ED-840P Petition Certification Form

ELECTRONIC VERSION
Form ED-840P
OMB Control No. 0610-0091
Expires:

U.S. DEPARTMENT OF COMMERCE
ECONOMIC DEVELOPMENT ADMINISTRATION

PETITION BY A FIRM FOR CERTIFICATION OF ELIGIBILITY
TO APPLY FOR TRADE ADJUSTMENT ASSISTANCE
No firm may be certified unless this petition is completed. (See 19 U.S.C. § 2341; 13 C.F.R. part 315)
E-MAIL TO:

[email protected]

OR
SUBMIT TO:

U.S. Department of Commerce, Economic Development Administration
Trade Adjustment Assistance Division
1401 Constitution Avenue N.W., Room 71030
Washington, D.C. 20230

ITEM 1 - PETITIONING FIRM
Petitioning firm (Use the legal name of the firm and indicate any trade name)
Name:
Address:
City:
State: AZ

Data Univ. Numbering System
(DUNS) No.:

Zip Code:

Congressional District:
Contact Person
First Name:
Last Name:
Title:
ITEM 2 - LEGAL FORM OF PETITIONING FIRM
Legal Form of petitioning firm (Please check appropriate box)

North American Industry
Classification System
(NAICS) Code (5-digit):

Telephone No. (Include Area

Code):

Salutation:

E-mail Address:

Other (please specify)________________
ITEM 3 - RELATED FIRMS
Check if one or more of the following apply and attach a detailed explanation (See General Instructions to Item 3):
Petitioning firm is a "successor firm."
Petitioning firm is a subsidiary, affiliate, predecessor, or otherwise related by common ownership or common control to
another firm. Indicate in the attached explanation whether the petitioning firm and the related firm sell or produce like or
directly competitive articles.
ITEM 4 - HISTORY OF PETITIONING FIRM
Attach a brief narrative describing the petitioning firm's economic history (See General Instructions to Item 4).
ITEM 5 - ARTICLES PRODUCED AND SOLD (Attach a separate sheet if necessary)
A.
Describe in detail the articles produced by the petitioning firm that are adversely affected by import competition,
including a brief description of the manufacturing process and the principal materials incorporated into the finished
articles.
B.

If applicable, describe in detail any other articles produced by the petitioning firm that are not adversely affected by
import competition.

C.

If applicable, describe in detail any finished articles purchased for resale by the petitioning firm and indicate whether such
articles are imported and from what country.

ITEM 6 - SALES/PRODUCTION DATA (See General Instructions to Item 6)
Annual Sales/Production for the most recent, and preceding year, are
reported on line 6A, notwithstanding the petition period checked in 6E.
Qualifying Sales/Production for the petition period checked in 6E are
reported on line 6C

Petition Time Period

(The time petition period checked in 6E. This period must be the
same for import data and employment data)

_____________
(Ending Date)

_____________
(Ending Date)

Percent Change

A. Total net sales or production of all article(s) or service(s) for the 12-month
period preceding the most recent 12-month period (left column) and the most
recent 12-month period (right column).

0.00%

B. Total net sales or production of all article(s) or service(s) for resale and/or exports
for the look-back period and for the most recent 12-month period (if the look-back
period is equal to or great than one year) or interim period (if the look-back period is
less than one year).
C. Qualifying total net sales or production for the look-back period and the most
recent 12-month period (if the look-back period is equal to or great than one year) or
interim period (if the look-back period is less than one year).

0.00%
0.00%

D. Specify if the sales or production decline is based on:
Net Sales
E. Specify whether the sales or production decline is based on:
The 12-month period preceding the most recent 12-month period.
The annual average of the 24-month period preceding the most recent 12-month period.
The annual average of the 36-month period preceding the most recent 12-month period.

Production

Interim decline. If checked, please specify the number of months:
F. Specify if one or more of the following apply:

Absolute decline of articles and/or services.
"25 percent" rule applies. Note; The "25 percent rule" cannot be used with interim petitions.
"Self-inflicted wound" (i.e., petitioning firm is purchasing the import-impacted articles offshore).
Sales decline is determined based on a bid or a quote.
ITEM 7 - IMPORT DATA (See General Instructions to Item 7 and attach additional sheets as necessary)
Petition Time Period
Harmonized Tariff Schedule (HTS) 6 DIGIT No.:
HTS No. Description:

_____________
(Ending Date)

_____________
(Ending Date)

Total Value of Imports in U.S. Dollars ($000s):

Percent Change

0.00%

ITEM 8 - EMPLOYMENT DATA (See General Instructions to Item 8)
Annual Employment for the most recent, and preceding year, are reported
on line 8A, notwithstanding of petition period checked in 6E. Qualifying
Employment for the petition period checked in 6E are reported on line 8B.
A. Monthly average employment for the 12-month period preceding the most
recent 12-month period (left column) and the most recent 12-month period (right
column).
B. Monthly average employment for the look-back period and the most recent 12month period (if the look-back period is equal to or great than one year) or interim
period (if the look-back period is less than one year).

C.

Petition Time Period
_____________
(Ending Date)

_____________
(Ending Date)

Percent Change

0.00%

0.00%

Specify if one or more of the following apply to the firm’s total employment:
There is an interim decline in employment (See 13 C.F.R. § 315.8). If checked, please specify the number of months:
There is a partial employee separation (A decline in worker hours or wages. See 13 C.F.R. § 315.2).
The threat of total or partial employee separation is imminent. Please attach supporting documentation (See 13 C.F.R. § 315.2).

An employee of the petitioning firm has petitioned the U.S. Department of Labor for certification of eligibility to apply
for Trade Adjustment Assistance for Workers. If so, please provide the following:
U.S. Department of Labor case number:
Describe the disposition (or current status) of the case:

ITEM 9 - FINANCIAL REPORTS (See General Instructions to Item 9)
In order of preference:
A) Attach one copy of the complete auditor's certified financial reports for the petitioning firm (including any subsidiaries, affiliates and
appropriate) covering the most recent and preceding year (6A), as well as the period covered by the petition (6C).

B) Publicly-owned corporations should furnish one copy of each Form 10-K annual report (or Form 10-Q quarterly report, as appropriate)

filed with the U.S. Securities and Exchange Commission for the entire period covered by the petition; or If certified financial reports are
not available, furnish one copy of the complete profit and loss statements, balance sheets and supporting statements prepared by the
petitioning firm's accountants covering the most recent and preceding year (6A), as well as the period covered by the petition (6C).

C) If financial statements are not produced or are generated infrequently, furnish one copy of the petitioning firm’s complete federal tax
returns covering the most recent and preceding year (6A), as well as the period covered by the petition (6C).

ITEM 10 - CUSTOMER LIST
During the investigation of a firm's petition, a representative group of the firm's customers will be contacted to determine whether there is a
relationship between any import-impacted sales and employment declines experienced by the firm and any increases in the value of like or
directly competitive articles or services being imported into the United States.

To facilitate this investigation, attach a separate sheet providing:
(i)
(ii)
(iii)
(iv)

the names and addresses of four (4) important current or important recent customers of the petitioning firm
(especially those that have reduced their purchases from the petitioning firm);
a synopsis of the interviews with at least two (2) customers or a representative group of the firm’s customers;
the names and business telephone numbers of contact persons for each customer; and
data on sales volume to each of the listed customers for the entire period covered by the petition.

If the petitioning firm does not have repeat customers, include a list of potential customers to whom the firm has submitted bids,
but lost contracts to foreign suppliers (copies of the lost bids should also be included). Include only customers who were active or
potential customers of the petitioning firm during the period covered by the petition.
If data gathered from the Harmonized Tariff Schedule (HTS) indicate a decrease in imports of like or directly competitive articles
or services, or if there is no HTS number available, then the TAAC must provide written certifications from a customer or
customers that account for a significant percentage of the firm's decline. HTS information should not be omitted from a petition
simply because it shows a decline in imports.
ITEM 11 - PETITION ASSISTANCE
Did the TAA certified firm received assistance in preparing their petition for certification? No
If so, please provide the requested contact information of anyone who assisted the firm in preparing their petition for certification.
Name:
Company:
Address:
City:

State:

Zip-Code:

E-mail Address:
Phone No.:
ITEM 12 - CERTIFICATION
The undersigned is an authorized representative of the petitioning firm and is executing this certification on behalf of the
petitioning firm. The undersigned hereby certifies that the information contained in or submitted with this petition is correct and
complete to the best of his/her knowledge and belief. U.S. Code, title 18 (Crimes and Criminal Procedure), Section 1001, makes it
a criminal offense to knowingly and willfully make any false statement or representation to any department or agency of the
United States as to any matter within its jurisdiction.
The petitioning firm certifies that it will comply with 13 C.F.R. § 315.14, which governs any employment of expediters for
Adjustment Assistance applications, and 13 C.F.R. § 315.15, which defines the petitioning firm’s conflicts of interest
responsibilities.
Signature of Petitioner’s Authorized Representative
Date
Print Name

Title

The undersigned is an authorized representative of the respective Trade Adjustment Assistance Center and is executing this
certification on behalf of the petitioning firm. The undersigned hereby certifies that the information contained in or submitted with
this petition is correct and complete to the best of his/her knowledge and belief. U.S. Code, title 18 (Crimes and Criminal
Procedure), Section 1001, makes it a criminal offense to knowingly and willfully make any false statement or representation to any
department or agency of the United States as to any matter within its jurisdiction.
Signature of TAAC Director
Date
Print Name

Title