APPLICATION FOR TRADE ADJUSTMENT ASSISTANCE (TAA) Complete all items in Sections A through D Mail to: SPECIAL CLAIMS OFFICE TRA STATE OF CALIFORNIA EMPLOYMENT DEVELOPMENT DEPARTMENT PO BOX 419076 RANCHO CORDOVA, CA 95741-9076 SECTION A: Worker Information Social Security Number Your Mailing Address Phone Number Where You Can be Reached ( Name of Affected Employer Employer's Mailing Address Date of First Separation from Affected Employment Dates of Subsequent Separations 1. 2. 3. SECTION C: Other Eligibility Information 1. Have you worked for any employer since your separation from the Employer shown in B above? Date Began Work Date of Separation 2. Have you filed an application for TAA prior to this application? 3. Have you filed a claim for Unemployment Insurance benefits since your separation from the affected employer? 4. How did you learn of the certification? SECTION D: Worker's Certification I have answered these questions for the purpose of applying for TAA benefits, knowing that the law provides penalties for making false statements. Signature of Worker: ____________________________________ Date Signed: ____________________________ Name (First) (MI) Apt. Female ) Subdivision or Department City Reason for Separation Reasons for Separations 1. 2. 3. Yes No Explain All "Yes" Answers Employer Name Address Reason for Separation State Where Filed Date Filed Type of Work You Did State Zip (Last) City Male State Birthdate Zip SECTION E: Department Use -TAA Certification Information Petition No: __________________ Certification Date: _____________ Impact Date: ________________ Termination Date: _____________ SECTION B: Employment Information Paying State ____________________________________________________ Name of Program SECTION F: Department Use - Field Office TAA specialists - Document Incumbent Worker requests for TAA pre-separation training. Worker must complete Section A � D, excluding separation information. Documentation Supporting Worker Threatened With Layoff/Termination From Affected Employment Identified From Employer List (Attach Letter From TAA Unit, Central Office) Notice From Employer (Attach Layoff Notice or Signed Statement) Other (Attach Supporting Document) Employer Contact Name Employer Contact Phone Number Employer Contact Fax Number Date of Initial Contact (On or After Cert Date) Expected Separation Date Worker Determined Incumbent (Complete DE 8320 IW and DE 2403T) Date Signed: F.O. # No Documentation to Support Worker is Threatened With Separation (Complete DE 8320 IW, Including Section E. Provide Copy to Worker) Interviewer Signature: DE 8309 Rev. 6 (8-09) (INT(RNET) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CU SOLICITUD DE BENEFICIOS PARA ASISTENCIA PARA AJUSTE DEL COMERCIO (TAA) Complete todos los incisos en las secciones de A a la D Env�e a: SPECIAL CLAIMS OFFICE TRA STATE OF CALIFORNIA EMPLOYMENT DEVELOPMENT DEPARTMENT PO BOX 419076 RANCHO CORDOVA, CA 95741-9076 SECCI�N A: Informaci�n sobre el Trabajador N�mero de Seguro Social Su Direcci�n Postal N�mero de Tel�fono Donde Podamos Comunicarnos con Ud. ( ) SECCI�N B: Informaci�n sobre el Empleo Nombre del Empleador Afectado Direcci�n Postal del Empleador Fecha de la Primera Separaci�n de Empleo Afectado Despu�s de la Fecha de Impacto Fechas de las Separaciones Posteriores 1. 2. 3. Subdivisi�n o Departamento Ciudad Raz�n de la Separaci�n Razones de las Separaci�nes 1. 2. 3. S� No Explique Todas las Respuestas que contest� "S�" Nombre del Empleador Direcci�n Raz�n de la Separaci�n Estado donde la Present� Fecha en que la Present� Clase de Trabajo que Ud. Hacia Estado C�digo Postal Nombre (Primero) (Segundo) Apto. Mujer (Apellidos) Ciudad Hombre Fecha de Nacimiento Estado C�digo Postal SECTION E: Department Use -TAA Certification Information Petition No: __________________ Certification Date: _____________ Impact Date: ________________ Termination Date: _____________ SECCI�N C: Otra Informaci�n para Determinar Elegibilidad 1. �Ha trabajado para alg�n empleador desde su separaci�n del Empleador indicado en B anteriormente? Fecha en que Empez� a Trabajar Fecha de la Separaci�n 2. �Ha presentado una solicitud para TAA antes de esta solicitud? 3. �Ha presentado una solicitud de beneficios del Seguro de Desempleo desde su separaci�n del empleador afectado? 4. �C�mo se enter� de la certificaci�n? SECCI�N D: CERTIFICACI�N DEL TRABAJADOR Estado que le Paga Beneficios ____________________________________________________ Nombre del Programa He contestado estas preguntas con el prop�sito de solicitar para beneficios de TAA con pleno conocimiento de que la ley provee sanciones por hacer declaraciones falsas. Firma del Trabajador: ____________________________________ Fecha en que se Firm�: ____________________________ SECTION F: Department Use - Field Office TAA specialists - Document Incumbent Worker requests for TAA pre-separation training. Worker must complete Section A � D, excluding separation information. Documentation Supporting Worker Threatened With Layoff/Termination From Affected Employment Identified From Employer List (Attach Letter From TAA Unit, Central Office) Notice From Employer (Attach Layoff Notice or Signed Statement) Other (Attach Supporting Document) Employer Contact Name Employer Contact Phone Number Employer Contact Fax Number Date of Initial Contact (On or After Cert Date) Expected Separation Date Worker Determined Incumbent (Complete DE 8320 IW and DE 2403T) Date Signed: F.O. # No Documentation to Support Worker is Threatened With Separation (Complete DE 8320 IW, Including Section E. Provide Copy to Worker) Interviewer Signature: DE 8309 Rev. 6 (8-09) (INT(RNET) Page 2 of 2 MIC 38/CU American LegalNet, Inc. www.FormsWorkFlow.com