The following information will be needed to qualify your firm for Trade Adjustment Assistance. All data should be for a two year period ending with the most recent month. Please answer with an "N/A" if not applicable and attach another sheet where additional space is needed. Please call the Southwest TAAC at 800 344-8872 if you need assistance.
TAAC PETITION INFORMATION
SECTION I
Are you a division of another firm? (If you are a division, please complete this form with information for the parent company, which will be the petitioning firm.)
Legal name of firm:__________________________________________
Firm address:________________________________________________
City:________________________________________________________
State:_______________________________________________________
Zip Code:____________________________________________________
County:______________________________________________________
Telephone:___________________________________________________
SIC Code(s):_________________________________________________
Fax #:_______________________________________________________
Contact and Title:___________________________________________
Are you a subsidiary of another firm? (If you are a subsidiary, please proceed, but indicate cash flows to and from the parent, or provide financials for the parent as well as yourself.)
Are you a corporation _________ Partnership _________ or Proprietorship ________
List the present owners and percentage owned by each:
Are any other firms owned or controlled by these owners? If so, please give name, address, and nature of the other business(es).
SECTION II
Please give a brief history of the firm, including founders and their present positions in the firm, when and where founded, and the names of any predecessor companies.
Type of business and markets:
Description of all goods and services provided:
Location and size of all facilities:
Markets served: regional ____ national ____ international ____
Names and title of Directors, Officers, and Key Managers:
Have there been any other significant events, such as natural disasters, fires, labor strikes, changes in product mix, etc. in the last five years? If so, explain:
SECTION III
List all articles produced that have been impacted by imports. For each, list the principle materials used, and describe the manufacturing process:
List other articles produced that are not affected by imports:
List articles purchased for resale; indicate if any are imported:
Last 12 mo. Previous 12 mo.
Sales for each impacted item
1.____________________________ ___________ _______________
2.____________________________ ___________ _______________
3.____________________________ ___________ _______________
4.____________________________ ___________ _______________
Sales for all non-impacted
items: ___________ _______________
Sales for all purchased
for resale items: ___________ _______________
TOTAL SALES
Net Value of intercompany
transactions: ___________ _______________
Net value of export sales: ___________ _______________
Number of customers who
placed orders: ___________ _______________
Average # of employees: ___________ _______________
Average # of production workers: ___________ _______________
Number of employees on impacted
products: ___________ _______________
Have any laid off employees petitioned the Labor Department for Trade Adjustment Assistance training? _____________________________
SECTION IV
Attach internal financials for the current YTD, and either audited financials or tax returns signed by an officer of the company for the last two fiscal years.
Attach only the first page, showing monthly employment totals, of the last eight quarters of your employment reports to the state.
Attach the list of customers of impacted products who purchased less this year than last year (blank forms attached).
Attach two copies of the sales literature for each impacted item.
Information prepared by:________________________
Date:_____________________
Title:______________________________
Return to: Southwest TAAC
1222 N. Main, Suite 740
San Antonio, Tx 78212
CUSTOMER LIST
The following customer information must be given in accordance with Item 12 of the Petition for Certification of eligibility. Sales volumes for the two comparative periods should correspond to the time frames used elsewhere in the petition. The U.S. Department of Commerce will contact these customers to verify that they are replacing your goods with imports so make sure to identify accounts that are significant to your firm and that show declines in sales volumes of at least 5% of the total net sales decline reported in the petition.
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Sales Data for Period ending: |
1. Name:
Address:
City/State:
Buyer:
Phone:
3. Name:
Address:
City/State:
Buyer:
Phone:
4. Name:
Address:
City/State:
Buyer:
Phone:
5. Name:
Address:
City/State:
Buyer:
Phone:
6. Name:
Address:
City/State:
Buyer:
Phone:
Revised 2/09/96