ETA Form 9042 "Petition for Trade Adjustment Assistance (Taa)"

What Is ETA Form 9042?

This is a legal form that was released by the U.S. Department of Labor - Employment & Training Administration on March 1, 2013 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2013;
  • The latest available edition released by the U.S. Department of Labor - Employment & Training Administration;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ETA Form 9042 by clicking the link below or browse more documents and templates provided by the U.S. Department of Labor - Employment & Training Administration.

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Download ETA Form 9042 "Petition for Trade Adjustment Assistance (Taa)"

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U.S. Department of Labor
Employment and Training Administration
OMB No. 1205-0342
Expires: 8/31/2019
Petition for Trade Adjustment Assistance (TAA)
About the Trade Adjustment Assistance (TAA) Program
The Trade Act of 1974 (19 USC § 2271 et seq.), as amended, established Trade Adjustment Assistance (TAA) to provide assistance to
workers in firms hurt by foreign trade. Program benefits include long-term training while receiving income support. TAA provides both
rapid and early assistance. Filing this petition is the first step in qualifying for TAA benefits and assistance. After the petition is filed,
the U.S. Department of Labor will determine whether a significant number or proportion of the workers of the firm have become total or
partially separated or are threatened to become totally or partially separated, and whether imports or a shift in production or services to
a foreign country contributed importantly to these actual or threatened separations and to a decline in sales or in production of articles
or supply of services. If a petition is approved and the workers are certified as eligible to participate in the TAA program, workers
covered by a certification may contact their state workforce agency to apply for benefits. These benefits are provided at no expense to
employers.
Filing Instructions
A group of three workers from the same firm, a union official, a state or local workforce agency representative in a local American
Job Center (also known as a One-Stop Career Center or by a different name), an employer official, or a legally authorized
representative must complete this Petition Form by answering all questions before submitting to the U.S. Department of Labor.
You must date and submit the Petition Form within 1 YEAR from the date on which the workers were separated or had their
hours and wages reduced.
You must file the Petition Form with both the U.S. Department of Labor in Washington, DC and the State TAA Coordinator or the
dislocated worker office of the state where the firm is located. To file with both the U.S. Department of Labor and the State TAA
Coordinator, electronically file the Petition Form on-line at http://www.etareports.doleta.gov/petition.
To file with the U.S. Department of Labor, use one of the methods below:
Fax the completed Petition Form to 202-693-3585, OR
Mail the completed Petition Form to the U.S. Department of Labor at:
U.S. Department of Labor
Office of Trade Adjustment Assistance
200 Constitution Ave NW, Room N-5428
Washington, DC 20210
To file with the State TAA Coordinator or the State Dislocated Worker Unit or State Workforce Agency
Use the contact information below to find the appropriate filing address. If this Petition Form includes locations in different states,
copies of this completed Petition Form must be filed in each state where firms are located.
Toll-Free Helpline:
1-877-US2-JOBS
(TTY) 1-877-889-5627
Internet:
http://www.doleta.gov/tradeact/contacts.cfm#State, or
http://www.servicelocator.org
For assistance in preparing a petition
Petitioners may receive assistance in preparing the petition at their local American Job Center, by contacting the U.S. Department of
Labor in Washington, D.C. at 202-693-3560 (Main Number), or by contacting their State Dislocated Worker Unit or State Workforce
Agency through the telephone numbers or internet addresses provided above
(29 CFR Part
90.11).
To check petition status
To check the status of your petition, please visit:
http://www.doleta.gov/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 USC 2321 and 2271). Public reporting burden
for this collection is estimated to average 20 minutes 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 state review. 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 at the address provided above (Paperwork Reduction Project 1205-0342).
Page 1 of 3
For more information, visit our Web site at
http://www.doleta.gov/tradeact
ETA-9042
Rev. March 2013
U.S. Department of Labor
Employment and Training Administration
OMB No. 1205-0342
Expires: 8/31/2019
Petition for Trade Adjustment Assistance (TAA)
About the Trade Adjustment Assistance (TAA) Program
The Trade Act of 1974 (19 USC § 2271 et seq.), as amended, established Trade Adjustment Assistance (TAA) to provide assistance to
workers in firms hurt by foreign trade. Program benefits include long-term training while receiving income support. TAA provides both
rapid and early assistance. Filing this petition is the first step in qualifying for TAA benefits and assistance. After the petition is filed,
the U.S. Department of Labor will determine whether a significant number or proportion of the workers of the firm have become total or
partially separated or are threatened to become totally or partially separated, and whether imports or a shift in production or services to
a foreign country contributed importantly to these actual or threatened separations and to a decline in sales or in production of articles
or supply of services. If a petition is approved and the workers are certified as eligible to participate in the TAA program, workers
covered by a certification may contact their state workforce agency to apply for benefits. These benefits are provided at no expense to
employers.
Filing Instructions
A group of three workers from the same firm, a union official, a state or local workforce agency representative in a local American
Job Center (also known as a One-Stop Career Center or by a different name), an employer official, or a legally authorized
representative must complete this Petition Form by answering all questions before submitting to the U.S. Department of Labor.
You must date and submit the Petition Form within 1 YEAR from the date on which the workers were separated or had their
hours and wages reduced.
You must file the Petition Form with both the U.S. Department of Labor in Washington, DC and the State TAA Coordinator or the
dislocated worker office of the state where the firm is located. To file with both the U.S. Department of Labor and the State TAA
Coordinator, electronically file the Petition Form on-line at http://www.etareports.doleta.gov/petition.
To file with the U.S. Department of Labor, use one of the methods below:
Fax the completed Petition Form to 202-693-3585, OR
Mail the completed Petition Form to the U.S. Department of Labor at:
U.S. Department of Labor
Office of Trade Adjustment Assistance
200 Constitution Ave NW, Room N-5428
Washington, DC 20210
To file with the State TAA Coordinator or the State Dislocated Worker Unit or State Workforce Agency
Use the contact information below to find the appropriate filing address. If this Petition Form includes locations in different states,
copies of this completed Petition Form must be filed in each state where firms are located.
Toll-Free Helpline:
1-877-US2-JOBS
(TTY) 1-877-889-5627
Internet:
http://www.doleta.gov/tradeact/contacts.cfm#State, or
http://www.servicelocator.org
For assistance in preparing a petition
Petitioners may receive assistance in preparing the petition at their local American Job Center, by contacting the U.S. Department of
Labor in Washington, D.C. at 202-693-3560 (Main Number), or by contacting their State Dislocated Worker Unit or State Workforce
Agency through the telephone numbers or internet addresses provided above
(29 CFR Part
90.11).
To check petition status
To check the status of your petition, please visit:
http://www.doleta.gov/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 USC 2321 and 2271). Public reporting burden
for this collection is estimated to average 20 minutes 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 state review. 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 at the address provided above (Paperwork Reduction Project 1205-0342).
Page 1 of 3
For more information, visit our Web site at
http://www.doleta.gov/tradeact
ETA-9042
Rev. March 2013
U.S. Department of Labor
Employment and Training Administration
OMB No. 1205-0342
Expires: 8/31/2019
Petition for Trade Adjustment Assistance (TAA)
Section 1. Petitioner Information
Provide petitioner information below. Three workers from the same firm completing this Petition Form must fill in all three
columns. Other petitioners need only fill in the Petitioner 1 column. A union official completing this petition form should
provide the name of the Union.
Petitioner 1
Petitioner 2
Petitioner 3
a)
Name
b)
Title
c)
Street Address
City
State, Zip
Phone – Main
d)
Phone – Alternate
e)
f)
E-mail
g)
Worker Separation Date
h)
Petitioner Type:
(please check one)
American Job Center
i)
Describe the worker group on whose behalf this petition is being filed:
Section 2. Workers’ Firm
Provide information on the firm employing the worker group. Complete items (a) – (g) regarding the employing firm. If the workers are
doing work at a location that is different than the worker’s employer (e.g., the petitioning workers are employed by a staffing agency but
work at a manufacturing firm), also complete items (h) – (m) regarding the firm at which the workers perform their jobs.
NOTE: Workers completing this Petition Form must provide information for the location where they work. All other petitioner types may
apply on behalf of more than one location. State offices and American Job Centers may file for workers at multiple locations of a firm
within their State. If you choose to file on behalf of workers at more than one location, please attach additional sheets as necessary.
Employer (Firm)
a)
Name of Firm
b)
Street Address
City
State, Zip
c)
Phone
d)
Website (if known)
e)
Describe the article produced or service supplied by this firm
f)
How many workers have been or may be separated (if known)?
g)
Is the firm or any part of the firm closing (if known)? If yes, when?
If the workers work at a location that is different from that listed in item a) and b), then fill out items h) through m) for that location:
h)
Name of Firm
i)
Street Address
City
State, Zip
j)
Phone
k)
Describe the article produced or service supplied by this firm
l)
How many workers have been or may be separated (if known)?
m)
Is the firm or any part of the firm closing (if known)? If yes, when?
Page 2 of 3
For more information, visit our Web site at
http://www.doleta.gov/tradeact
ETA-9042
Rev. March 2013
U.S. Department of Labor
Employment and Training Administration
OMB No. 1205-0342
Expires: 8/31/2019
Petition for Trade Adjustment Assistance (TAA)
Section 3. Trade Effects on Separations
1. To the best of your knowledge, provide reasons why you believe that separations that have occurred or may be threatened at the
workers’ firm are due to foreign trade. (Example: Production has been/is being shifted to a foreign country, services are being
outsourced to a foreign country, increased imports of articles or services, loss of business with a TAA-certified firm.)
2. If you possess any additional information or documents that you believe may assist in the determination of whether the worker group
is eligible for TAA benefits, submit it as an attachment to the Petition Form. Check the box below if you have attached any additional
information or supporting documents.
I have attached additional information or supporting documents.
3. Provide contact information for two company officials, one of whom should be a dislocated worker’s supervisor. Either separately or
together, these officials should be familiar with all of the following: employment, job functions, and sales or production at each job
location.
Official 1
Official 2
a)
Name
b)
Title
Phone – Main
c)
Phone – Alternate
d)
e)
Fax
f)
E-mail
Section 4. 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 whether the worker group is eligible.
Knowingly falsifying any information on this Petition Form is a Federal offense (18 USC § 1001) and a violation of the Trade Act (19
USC § 2316). For this petition to be valid, each of the petitioners listed in Question 1 must sign below and the Petition Fo rm must be
dated. By signing below, you agree to the following statements:
“I declare that to the best of my knowledge and belief the information I have provided is true, correct, and
complete.”
a)
Signature
b)
Name (Print)
c)
Date of Petition
Page 3 of 3
For more information, visit our Web site at
http://www.doleta.gov/tradeact
ETA-9042
Rev. March 2013
Page of 3