De8309 8309
User Manual: 8309
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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 E: Department Use -TAA Certification Information Petition No: __________________ Impact Date: ________________ Certification Date: _____________ Termination Date: _____________ SECTION A: Worker Information Social Security Number Name (First) (MI) Your Mailing Address Phone Number Where You Can be Reached ( (Last) Apt. City Female Male Birthdate State Zip ) SECTION B: Employment Information Name of Affected Employer Subdivision or Department Employer’s Mailing Address City Date of First Separation from Affected Employment Reason for Separation Dates of Subsequent Separations 1. Reasons for Separations 1. 2. 2. 3. 3. SECTION C: Other Eligibility Information Yes Type of Work You Did State No Zip Explain All “Yes” Answers 1. Have you worked for any employer since your separation from the Employer shown in B above? Date Began Work Employer Name Address Date of Separation Reason for Separation 2. Have you filed an application for TAA prior to this application? State Where Filed 3. Have you filed a claim for Unemployment Insurance benefits since your separation from the affected employer? Date Filed Paying State ____________________________________________________ Name of Program 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: ____________________________ 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) Employer Contact Name Employer Contact Phone Number Date of Initial Contact (On or After Cert Date) Expected Separation Date 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) (INTERNET) Other (Attach Supporting Document) Employer Contact Fax Number Worker Determined Incumbent (Complete DE 8320 IW and DE 2403T) Date Signed: Page 1 of 2 F.O. # CU SOLICITUD DE BENEFICIOS PARA ASISTENCIA PARA AJUSTE DEL COMERCIO (TAA) Complete todos los incisos en las secciones de A a la D Envíe a: SPECIAL CLAIMS OFFICE TRA STATE OF CALIFORNIA EMPLOYMENT DEVELOPMENT DEPARTMENT PO BOX 419076 RANCHO CORDOVA, CA 95741-9076 SECTION E: Department Use -TAA Certification Information Petition No: __________________ Impact Date: ________________ Certification Date: _____________ Termination Date: _____________ SECCIÓN A: Información sobre el Trabajador Número de Seguro Social Nombre (Primero) (Segundo) (Apellidos) Su Dirección Postal Apto. Ciudad Número de Teléfono Donde Podamos Comunicarnos con Ud. ( ) Mujer Hombre Fecha de Nacimiento Estado Código Postal SECCIÓN B: Información sobre el Empleo Nombre del Empleador Afectado Subdivisión o Departamento Dirección Postal del Empleador Ciudad Fecha de la Primera Separación de Empleo Afectado Después de la Fecha de Impacto Razón de la Separación Fechas de las Separaciones Posteriores 1. Razones de las Separaciónes 1. 2. 2. 3. 3. SECCIÓN C: Otra Información para Determinar Elegibilidad Clase de Trabajo que Ud. Hacia Estado Sí No 1. ¿Ha trabajado para algún empleador desde su separación del Empleador indicado en B anteriormente? Fecha en que Empezó a Trabajar Código Postal Explique Todas las Respuestas que contestó “Sí” Nombre del Empleador Dirección Fecha de la Separación Razón de la Separación 2. ¿Ha presentado una solicitud para TAA antes de esta solicitud? Estado donde la Presentó 3. ¿Ha presentado una solicitud de beneficios del Seguro de Desempleo desde su separación del empleador afectado? Fecha en que la Presentó Estado que le Paga Beneficios ____________________________________________________ Nombre del Programa 4. ¿Cómo se enteró de la certificación? SECCIÓN D: CERTIFICACIÓN DEL TRABAJADOR He contestado estas preguntas con el propósito 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 Firmó: ____________________________ 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) Employer Contact Name Employer Contact Phone Number Date of Initial Contact (On or After Cert Date) Expected Separation Date 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) (INTERNET) Other (Attach Supporting Document) Employer Contact Fax Number Worker Determined Incumbent (Complete DE 8320 IW and DE 2403T) Date Signed: Page 2 of 2 F.O. # MIC 38/CU
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