Form ED-840P Pettition by a Firm for Certification of Eligibility to

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Form ED-840P U.S.
OMB Control No. 0610-0091
Expires:

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)
FOR GOVERNMENT USE ONLY
E-MAIL TO:
TAAC@eda.doc.gov
Project Number
Date Accepted
OR
for Filing
SUBMIT TO: U.S. Department of Commerce Economic Development
Administration Trade Adjustment Assistance Program Manager
1401 Constitution Avenue, N.W., Room 7009
Washington, D.C. 20230

ITEM 1 - PETITIONING FIRM
Name and address of petitioning firm (Use the legal name of the firm and indicate any trade name)
Company Name:
Address:
City:
State:
Zip Code:
Contact Person
First Name:
Last Name:
Title:
Salutation: Mr.
ITEM 2 - LEGAL FORM OF PETITIONING FIRM
Legal Form of petitioning firm (Please check appropriate box)
Partnership

Telephone Number
(Include Area Code):

E-mail Address:

If 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".
No
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
No
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)
Petition Time Period
(This period should be the same for import data and employment data)

_____________
(Ending Date)

_____________
(Ending Date)

A. Total net sales or production of all articles produced by the
petitioning firm.

Percent Change

0.00%

B. Total net sales of all articles purchased for resale by the

0.00%

petitioning firm

C. Total net sales or production of all import-impacted articles
produced by the petitioning firm.

0.00%

D. Specify if one or more of the following apply to the sales of the import-impacted articles (See 13 C.F.R. § 315.2 and 315.7(b)(1)):

Absolute decline in sales of the import-impacted articles.
Interim decline in sales of the import-impacted articles. If checked, please specify the number of months: _________
"25 percent" rule applies.
"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)
DUNS Number:

Petition Time Period

NAICS (5-digit):

Harmonized Tariff Schedule (HTS) No.:

HTS No. Description:

_____________
(Ending Date)

_____________
(Ending Date)

Percent Change

0.00%

Total Value of Imports in U.S. Dollars ($000s):
ITEM 8 - EMPLOYMENT DATA (See General Instructions to Item 8)
Petition Time Period
_____________
(Ending Date)

_____________
(Ending Date)

Percent Change

A.

Petitioning firm's total monthly average
employment.

0.00%

B.

Petitioning firm's total monthly average
employment of production and related workers for
all import-impacted articles.

0.00%

C.

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).
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 dcoumentation.(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
Attach one (1) copy of the complete auditor's certified financial reports for the petitioning firm (including any subsidiaries,
affiliates and other related entities) for the entire period covered by the petition. If certified financial statements are not available,
furnish one (1) copy of the complete profit and loss statements, balance sheets and supporting statements prepared by the
petitioning firm's accountants for the entire period covered by the petition. Publicly-owned corporations should furnish one (1)
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.
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 being imported into the United States. To facilitate this investigation, attach a
separate sheet providing:
(i)
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);
(ii)
the names and business telephone numbers of contact persons for each customer; and
(iii)
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.
ITEM 11 - PETITION ASSISTANCE
If a Trade Adjustment Assistance Center ("TAAC") helped prepare this petition, please identify the TAAC and the name and
telephone number of your contact person at the TAAC. Additionally, please identify the name, business address and telephone
number of anyone outside of the petitioning firm and the TAAC who assisted in preparing this petition.
TAAC Name:
Address:
City, State, Zip-Code:
Contact Name:

Contact E-mail:

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.
Name of Authorized Representative

Signature of Authorized Representative

Title

Date