Form Taa-1035a - Taa Exit Report
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
TAA-1035A FORFF (12-17)
Workforce Development Administration (WDA)
Trade Adjustment Assistance (TAA) Program
TAA EXIT REPORT
PARTICIPANT NAME
PARTICIPANT ID
TAA COUNSELOR
PETITION NO.
TAA EXIT DATE (90 days after final TAA/WIOA service)
SERVICES
Did the participant receive:
Wagner-Peyser Services?
Yes
No
If yes, date of last service:
WIOA Services?
Yes
No
If yes, date of last service:
TRA?
Yes
No
If yes, type:
Basic
Additional
Completion End date of final week:
Job Search Allowance?
Yes
No
If yes, date received:
Relocation Allowance?
Yes
No
If yes, date received:
RTAA?
Yes
No
If yes, date received:
TRAINING
Did the participant receive training?
Yes
No
If yes, training was:
Completed
Terminated
Withdrawn End date of final week:
CO-FUNDING
Did the participant receive co-funding through:
WIOA/Dislocated Worker Program?
Yes
No
Other federally-funded program?
Yes
No
Program name:
EMPLOYMENT INFORMATION
Reemployment Status:
Did participant become employed following the final TAA/WIOA service?
Yes
No
Name of Employer:
Start Date:
Is the new employment related to training?
Yes
No
Is the participant self-employed?
Yes
No
TAA COUNSELOR VERIFICATION
COMMENTS
TAA Counselor Signature
DATE
Supervisor Signature
DATE
Original to participant’s file
Copy to
TAAProgram@azdes.gov
See reverse for EOE/ADA/LEP/GINA disclosures
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