Form Eta-9042 - Petition For Trade Adjustment Assistance (Taa) - 2011
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1
2U.S. Department of Labor
Employment and Training Administration
OMB No. 1205-0342
Expires: 1/31/2013
Petition for Trade Adjustment Assistance (TAA)
Section 1. Petitioner Information
Provide petitioner information below. Three workers from the same job location 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:
(Union Name_______)
(please check one)
One-
Other Authorized Represent
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 One-Stop Operators/Partners 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?
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ETA-9042
Rev. October 2011
Previous forms not usable
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