Web App Test Petition

U.S. Department of Labor
Employment and Training Administration
Office of Trade Adjustment Assistance

OMB No. 1205-0342
Expires: 09/30/2022

Petition for Trade Adjustment Assistance (TAA) for Workers

INSTRUCTIONS FOR COMPLETING THE FORM
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, and the Reemployment Trade Adjustment
Assistance benefit for workers aged 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 the filing of a Petition, the Department of Labor (Department) conducts an
investigation to determine whether foreign trade contributed importantly to the workers' job separation 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 agency representative will notify workers in a certified group of the determination, at which time the individual workers
may apply for benefits and services at a local American Job Center. For a worker to be eligible for benefits and services, the worker
must be part of a worker group that has been certified under a petition filed with the Department. Additional information is available
on our website at: https://www.dol.gov/agencies/eta/tradeact/.

Filing Instructions. A petition for certification of eligibility to apply for adjustment assistance for a group of workers must be

filed simultaneously with the Secretary of Labor and with the Governor of the State in which such workers' firm is located.
Information provided on the petition form will be used for the purposes of determining worker group eligibility, and providing notice
to the general public that the petition has been filed and whether the worker group is eligible to apply for TAA Program benefits and
services. A valid petition form, including attachments, is treated as a public document.
Amendments to active existing TAA certifications will be investigated based on the information provided by the petitioner(s) on the
TAA petition form. If the petitioners would like the Department to consider whether an amendment to an existing certification is
appropriate, the petitioners should include in the petition any information they would like considered and can include a statement
that they believe that an amendment would be appropriate. Identifying a petition as an amendment request does not preclude or
limit a full investigation of the petition.

Who May File a Petition?
A group of two or more workers from the same firm; a union or other duly authorized representative of such workers; the
firm(s) of such workers; American Job Center operators or partners, including State workforce officials, employment security
agencies, or dislocated worker unit and rapid response team members. Department of Labor.

How to File a Valid Petition:
The following information must be completed for a petition to be considered valid: (1) the name and contact information for
each petitioner; (2) the name of the firm employing the group of workers; (3) the address of the location(s) where the group of
workers who have been totally or partially separated or threatened with separation report to work (for a remote worker, the
address of the location to which they report); (4) the name and contact information of an official within the employer firm or
an individual authorized to provide information regarding the operation of the workers' firm; (5) the article produced or service
supplied by the workers' firm; (6) the actual or approximate date on which total or partial separations are threatened to occur
or did occur; (7) the actual or estimated total number of workers who have been or may be separated; and (8) every petition
shall be signed and dated by at least two individuals of the petitioning group, or by an official of a certified or recognized
union or other duly authorized representative, or by a representative of one of the organizations listed in the Who May File a
Petition section above. Required items are indicated on the Petition Form with an asterisk (*).

How to File a Petition with the U.S. Department of Labor:
There are three methods to file a petition with the Department. Please submit the petition using only one of the methods below;
submitting the same petition using multiple methods will not speed the investigation process and may slow the process.
The most effective way to file a Petition is to complete the Petition form online at https://www.etareports.doleta.gov/petition.

FILING ONLINE IS STRONGLY ENCOURAGED; OR

Fax the completed Petition form to (202) 693-3584, (202) 693-3585, (202) 693-3986; OR
Mail the completed Petition form to:
U.S. Department of Labor
Office of Trade Adjustment Assistance
200 Constitution Ave NW, Room N-5428
Washington, DC 20210

Page 1 of 5

For more information, visit our Web site at http://www.dol.gov/agencies/eta/tradeact/

ETA-9042A-1 (Rev. 04/09) Petition Form
Submitted on April 22, 2020.

U.S. Department of Labor
Employment and Training Administration
Office of Trade Adjustment Assistance

OMB No. 1205-0342
Expires: 09/30/2022

Petition for Trade Adjustment Assistance (TAA) for Workers
To File with the State TAA Coordinator or the State Dislocated Worker Unit or State Workforce Agency (SWA):
Use the contact information below to find the appropriate SWA filing address. If this Petition includes worker
separations in different states, copies of this completed Petition Form must be filed with each state with worker
separations.
Toll-Free
1-877-US2-JOBS (TTY) 1-877-889-5627
Helpline:
Internet: https://www.dol.gov/agencies/eta/tradeact/contact/states/, or
https://www.careeronestop.org/

For Filing Assistance:
A worker may contact their local American Job Center or their State Dislocated Worker Unit or State Workforce Agency for
assistance in preparing a Petition or to request submission of a petition on the workers' behalf. The contact information can
be obtained using the telephone numbers or internet addresses provided above. For any questions about filing a Petition, a
petitioner may also contact the Office of Trade Adjustment Assistance hotline number at (888) 365-6822.

To Check on Filing Status:
To check the status of your petition, please visit: http://www.dol.gov/agencies/eta/tradeact/

Public Burden Statement
Persons are not required to respond to this collection of information unless it displays a currently valid Office of Management and
Budget (OMB) control number. Responding is required to obtain or maintain benefits (19 U.S.C. 2271). Public reporting burden for
this collection is estimated to average 0.33 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, completing and reviewing the collection of information, and a potential
review by a state official. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden of this collection, to the U.S. Department of Labor at the address provided above
(Paperwork Reduction Project 1205-0342).

Page 2 of 5

For more information, visit our Web site at http://www.dol.gov/agencies/eta/tradeact/

ETA-9042A-1 (Rev. 04/09) Petition Form
Submitted on April 22, 2020.

U.S. Department of Labor
Employment and Training Administration
Office of Trade Adjustment Assistance

OMB No. 1205-0342
Expires: 09/30/2022

Petition for Trade Adjustment Assistance (TAA) for Workers
Section 1. Petitioner Information
Please provide petitioner information below. A company, state workforce, American Job Center, union or duly authorized official will
generally complete all information in column 1 (Note: a union official completing this petition form should provide the name of the
union.) Otherwise, two workers from the same firm completing this Petition Form must complete fields under both Petitioner 1 and
Petitioner 2 headings.
Petitioning Worker 1

Petitioning Worker 2

a)

Name

Pet1First Pet1Last

Pet2First Pet2Last

b)

Title

Pet1Title

Pet2Title

c)

Street Address

Pet1Address

Pet2Address

City

Pet1City

Pet2City

State, Zip

AK, 20001

AL, 20002

d)

Phone - Main

608-354-0001

608-354-1001

e)

Phone - Alternate

608-354-0002

608-354-1002

f)

E-mail

hoekstra.robert1@dol.gov

g)

Petitioner Type:

Two Workers

Union Official: Union Name

Section 2. Affirmation of Information
The information you provide on this petition form will be used for the purposes of determining worker group eligibility and providing
notice to petitioners, workers, and the general public that the petition has been filed and subsequently whether the worker group is
determined to be eligible to apply for TAA benefits and services. 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). For the petition to be
valid, the petitioner(s) listed in Section 1 - Petitioner Information must sign and date below, attesting to the fact that they are
authorized to file a petition.
a) Signature

/s/ Pet1First Pet1Last

/s/ Pet2First Pet2Last

b) Name (Print)

Pet1First Pet1Last

Pet2First Pet2Last

c)

April 22, 2020

Date of Petition

Page 3 of 5

For more information, visit our Web site at http://www.dol.gov/agencies/eta/tradeact/

ETA-9042A-1 (Rev. 04/09) Petition Form
Submitted on April 22, 2020.

U.S. Department of Labor
Employment and Training Administration
Office of Trade Adjustment Assistance

OMB No. 1205-0342
Expires: 09/30/2022

Petition for Trade Adjustment Assistance (TAA) for Workers
Section 3. Firm Employing the Group of Workers
Please provide information on the firm employing the group of workers on whose behalf the petition is being filed. Complete items
(a) to (e) regarding the employing firm.
Employer (Firm)
a) Name of Employer Firm*
b) U.S. Headquarters Street Address*

c)
d)
e)

City*
State*, Zip*
Phone
Website (if known)
Describe the article produced or service supplied by this firm

EmployerFirm Name
EmployerFirm Address
EmployerFirm City
AR, 30001
608-354-2001
http://www.firmwebaddress.com
EmployerFirm Product or Service

Section 4. Group of Workers
Please provide information on the location where the group of workers (who are filing the petition or on whose behalf the petition is
being filed) report to work or physically work. Workers may apply only on behalf of workers at the same location at which both
petitioning workers' are employed. A company official may apply on behalf of workers at any location at which the company
employs a group of workers. A union may apply only on behalf of workers at a location where the union represents bargaining unit
workers. A duly authorized representative may apply only on behalf of the workers at the same location at which the worker(s) who
the petitioner represents are employed.
If you choose to file on behalf of a group of workers at more than one location, please attach additional sheets as necessary.
a) Name of Firm
wg Name
b) Street Address*
wg Address

c)
d)
e)
f)
g)

City*
State*, Zip*
Phone*
How many workers have been or may be separated?*
When did worker separations occur or when are separations threatened
to occur? (Estimated date may be listed if exact date is not known.)*
Work activities of the group of workers on whose behalf the petition is
filed.*
Indicate if and when the location has closed or will be closing

Page 4 of 5

wg City
CA, 40001
608-354-3001
100
04/22/2020
wg Activities
Closing 05/22/2020

For more information, visit our Web site at http://www.dol.gov/agencies/eta/tradeact/

ETA-9042A-1 (Rev. 04/09) Petition Form
Submitted on April 22, 2020.

U.S. Department of Labor
Employment and Training Administration
Office of Trade Adjustment Assistance

OMB No. 1205-0342
Expires: 09/30/2022

Petition for Trade Adjustment Assistance (TAA) for Workers
Section 5. Trade Effects of Separations
1. To the best of your knowledge, please summarize below the reasons why you believe that foreign trade contributed
importantly to worker separations that have occurred, may occur, or are threatened to occur at the workers' firm (identified
within Sec. 4a and 4b) as articulated under Sec. 222 of the Act or summarize the reasons you are requesting to amend an
existing and active certification. (Examples: Articles or services have been/is being shifted to a foreign country; acquisition
of articles or services from a foreign country; firm and/or customer imports of articles or services from a foreign country;
loss of business with a firm that employed a worker group now determined to be eligible to apply for TAA; an affirmative
finding by the International Trade Commission.)
trade effects
2. If you possess any additional information or documents that you believe may assist in the determination of whether the
group of workers is eligible for TAA benefits, submit that information as an attachment to the Petition Form. Check the box
below if you have attached any additional information or supporting documents.
I have attached 1 (No of pages) of additional information or supporting documents.
organizational_chart.pdf

Section 6. Company Contact Information
Provide contact information for one or more company officials, one of whom should be a supervisor of the group of workers or
someone authorized to provide information regarding the group of workers' firm. (Example: Legal counsel, bankruptcy trustee,
etc.). Either separately or together, these officials should be familiar with the operations of the group of workers' firm.
a)
b)
c)
d)

e)
f)
g)
h)

Name of Official*
Title of Official*
Official's Firm Name
Street Address
City
State, Zip
Phone - Main
Phone - Alternate
Fax
E-mail

Page 5 of 5

Official 1
off1First off1Last
off1Title
off1FirmName
off1Address
off1City
DC, 40001
608-354-5001
608-354-5002
608-354-5003
hoekstra.robert3@dol.gov

Official 2
off2First off2Last
off2Title
off2FirmName
off2Address
off2City
DE, 50001
608-354-6001
608-354-6002
608-354-6003
hoekstra.robert4@dol.gov

For more information, visit our Web site at http://www.dol.gov/agencies/eta/tradeact/

ETA-9042A-1 (Rev. 04/09) Petition Form
Submitted on April 22, 2020.